case study about anxiety disorder pdf

“I Don’t Want to Bother You” – A Case Study in Social Anxiety Disorder

• First Online: 29 March 2023

Cite this chapter

• Katharine E. Daniel 3 &
• Bethany A. Teachman 3  

Part of the book series: CBT: Science Into Practice ((CBT))

560 Accesses

1 Altmetric

Gi, a 34-year-old second-generation Korean American man, presented to treatment with pronounced and longstanding anxiety in many social situations, which significantly impaired his functioning (e.g., his perceived ability to run errands in crowded stores and care for his ill father). Gi engaged in cognitive behavior therapy (CBT) via telehealth during the COVID-19 pandemic. Key cognitions and biased cognitive processes that were maintaining his anxiety included a judgment that others frequently reject him, an assumption that if he expressed his own needs, then he would be unreasonably burdening others, and a core belief that he was incompetent, along with a pervasive tendency to make negative interpretations about his abilities in most social situations. He experienced marked functional improvements and reduced anxiety throughout his 17-session course of treatment. Gi’s case and treatment are detailed throughout this chapter to illustrate how individual CBT for social anxiety disorder can be implemented. Special discussion of how the clinician continuously and collaboratively modified her case conceptualization and intervention approaches with reference to aspects of Gi’s identities and in response to her own missteps are offered throughout.

This is a preview of subscription content, log in via an institution to check access.

Access this chapter

Subscribe and save.

• Get 10 units per month
• Download Article/Chapter or eBook
• 1 Unit = 1 Article or 1 Chapter
• Cancel anytime
• Available as PDF
• Read on any device
• Instant download
• Own it forever
• Available as EPUB and PDF
• Compact, lightweight edition
• Dispatched in 3 to 5 business days
• Free shipping worldwide - see info
• Durable hardcover edition

Tax calculation will be finalised at checkout

Purchases are for personal use only

Institutional subscriptions

Similar content being viewed by others

Cultural Considerations in Behavioral Health Service Delivery for Social Anxiety

Generalized Anxiety Disorder in Canadian Adults: to what Extent Might Social Support Subdomains and Negative Social Interactions Predict Psychological Distress?

DINOSAUR: an integrated cognitive-behavioral treatment for anxiety in young children with ASD

Anxiety & Depression Association of America. (1.12.2022). Social anxiety disorder. https://adaa.org/understanding-anxiety/social-anxiety-disorder .

Beck, J. S. (2020). Cognitive behavior therapy: Basics and beyond (3rd ed.). Guilford Press.

Google Scholar  

Craske, M. G., Treanor, M., Conway, C. C., Zbozinek, T., & Vervliet, B. (2014). Maximizing exposure therapy: An inhibitory learning approach. Behaviour Research and Therapy, 58 , 10–23. https://doi.org/10.1016/j.brat.2014.04.006

Article   PubMed   PubMed Central   Google Scholar  

Foa, E. B., & Kozak, M. J. (1986). Emotional processing of fear: Exposure to corrective information. Psychological Bulletin, 99 , 20–35. https://doi.org/10.1037/0033-2909.99.1.20

Article   PubMed   Google Scholar  

Gover, A. R., Harper, S. B., & Langton, L. (2020). Anti-Asian hate crime during the COVID-19 pandemic: Exploring the reproduction of inequality. American Journal of Criminal Justice , 1–21. https://doi.org/10.1007/s12103-020-09545-1

Harpole, J. K., Levinson, C. A., Woods, C. M., Rodebaugh, T. L., Weeks, J. W., Brown, P. J., Heimberg, R. G., Menatti, A. R., Blanco, C., Schneier, F., & Liebowitz, M. (2015). Assessing the straightforwardly-worded Brief Fear of Negative Evaluation scale for differential item functioning across gender and ethnicity. Journal of Psychopathology and Behavioral Assessment, 37 (2), 306–317. https://doi.org/10.1007/s10862-014-9455-9

Hayes, S. C., Strosahl, K. D., & Wilson, K. G. (2012). Acceptance and commitment therapy: The process and practice of mindful change (2nd ed.). The Guilford Press.

Leahy, R. L., Holland, S. J. F., & McGinn, L. K. (2012). Treatment plans and interventions for depression and anxiety disorders (2nd ed.). Guilford Press.

Miller, W. R., & Rollnick, S. (2012). Motivational interviewing: Helping patients change behavior (3rd ed.). Guilford Press.

Norton, P. J., & Weeks, J. W. (2019). A multi-ethnic examination of social evaluative fears. Journal of Anxiety Disorders, 23 , 904–908. https://doi.org/10.1016/j.janxdis.2009.05.008

Article   Google Scholar  

Piccirillo, M. L., Taylor Dryman, M., & Heimberg, R. G. (2016). Safety behaviors in adults with social anxiety: Review and future directions. Behavior Therapy, 47 (5), 675–687. https://doi.org/10.1016/j.beth.2015.11.00

Turner, S. M., Johnson, M. R., Beidel, D. C., Heiser, N. A., & Lydiard, R. B. (2003). The social thoughts and beliefs scale: A new inventory for assessing cognitions in social phobia. Psychological Assessment, 15 (3), 384–391. https://doi.org/10.1037/1040-3590.15.3.384

Download references

Author information

Authors and affiliations.

Department of Psychology, University of Virginia, Charlottesville, VA, USA

Katharine E. Daniel & Bethany A. Teachman

You can also search for this author in PubMed   Google Scholar

Corresponding author

Correspondence to Bethany A. Teachman .

Editor information

Editors and affiliations.

Mental Health Research and Treatment Center, Faculty of Psychology, Ruhr-University Bochum, Bochum, Germany

Marcella L. Woud

Rights and permissions

Reprints and permissions

Copyright information

© 2023 The Author(s), under exclusive license to Springer Nature Switzerland AG

About this chapter

Daniel, K.E., Teachman, B.A. (2023). “I Don’t Want to Bother You” – A Case Study in Social Anxiety Disorder. In: Woud, M.L. (eds) Interpretational Processing Biases in Emotional Psychopathology . CBT: Science Into Practice. Springer, Cham. https://doi.org/10.1007/978-3-031-23650-1_16

Download citation

DOI : https://doi.org/10.1007/978-3-031-23650-1_16

Published : 29 March 2023

Publisher Name : Springer, Cham

Print ISBN : 978-3-031-23649-5

Online ISBN : 978-3-031-23650-1

eBook Packages : Behavioral Science and Psychology Behavioral Science and Psychology (R0)

Share this chapter

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

• Publish with us

Policies and ethics

• Find a journal
• Track your research

An official website of the United States government

The .gov means it’s official. Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

The site is secure. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

• Publications
• Account settings

Preview improvements coming to the PMC website in October 2024. Learn More or Try it out now .

• Advanced Search
• Journal List
• Health Psychol Res
• v.2(3); 2014 Nov 6

A Cognitive-Behavior Therapy Applied to a Social Anxiety Disorder and a Specific Phobia, Case Study

Contributions: AP and GT designed the protocol, administer the CBT therapy sessions, analyzed and interpreted the data, and wrote the paper.

George, a 23-year-old Greek student, was referred by a psychiatrist for treatment to a University Counseling Centre in Athens. He was diagnosed with social anxiety disorder and specific phobia situational type. He was complaining of panic attacks and severe symptoms of anxiety. These symptoms were triggered when in certain social situations and also when travelling by plane, driving a car and visiting tall buildings or high places. His symptoms lead him to avoid finding himself in such situations, to the point that it had affected his daily life. George was diagnosed with social anxiety disorder and with specific phobia, situational type (in this case acrophobia) and was given 20 individual sessions of cognitivebehavior therapy. Following therapy, and follow-up occurring one month post treatment, George no longer met the criteria for social phobia and symptoms leading to acrophobia were reduced. He demonstrated improvements in many areas including driving a car in and out of Athens and visiting tall buildings.

Introduction

Social anxiety disorder (SAD), also known as social phobia, is one of the most common anxiety disorders. Social phobia can be described as an anxiety disorder characterized by strong, persisting fear and avoidance of social situations. 1 , 2 According to DSMIV, 3 the person experiences a significant fear of showing embarrassing reactions in a social situation, of being evaluated negatively by people they are not familiar with and a desire to avoid finding themselves in the situations they fear. 4 , 5 Furthermore people with generalized social phobia have great distress in a wide range of social situations. 6 The lack of clear definition of social phobia has been reported by clinicians and researchers because features of social phobia overlap with those of other anxiety disorders such as specific panic disorder, agoraphobia and shyness. 7

According to ICD-10, 8 phobic anxiety disorders is a group of disorders in which anxiety is evoked only, or predominantly, in certain well-defined situations that are not currently dangerous. As a result these situations are characteristically avoided or endured with dread. The patient’s concern may be focused on individual symptoms like palpitations or feeling faint and is often associated with secondary fears of dying, losing control, or going mad. Contemplating entry to the phobic situation usually generates anticipatory anxiety. Phobic anxiety and depression often coexist. Whether two diagnoses, phobic anxiety and depressive episode, are needed, or only one, is determined by the time course of the two conditions and by therapeutic considerations at the time of consultation.

Prevalence of social phobia varies from 0-20%, depending on differences in the classification criteria, culture 9 , 10 and gender. 11-13 The onset of the disorder is considered to take place between the middle and late teens. 14 The NICE guidelines for social anxiety disorder, describe it as one of the most common of the anxiety disorders. Estimates of lifetime prevalence vary but according to a US study, 12% of adults in the US will have social anxiety disorder at some point in their lives, compared with estimates of around 6% for generalized anxiety disorder (GAD), 5% for panic disorder, 7% for post-traumatic stress disorder (PTSD) and 2% for obsessive-compulsive disorder. There is a significant degree of comorbidity between social anxiety disorder and other mental health problems, most notably depression (19%), substance-use disorder (17%), GAD (5%), panic disorder (6%), and PTSD (3%). 15

Social phobia is also developed and maintained by complex physiological, cognitive, and behavioral mechanisms. Biological causes of social anxiety/phobia have been reported by some researchers while others look on behavioral inhibition 16 and the effects of personality traits such as neuroticism and introversion 17 as the mediators between genetic factors and social phobia.

Apart from the biological factor, the role of cognition in the acquisition and maintenance of social anxiety/phobia is very important. The main cognitive factor is the fear of negative evaluation. 18 Beck, Emery, and Greenberg 19 associated the possibility of negative evaluation by others with beliefs of general social inadequacy, concerns about the visibility of anxiety, and preoccupation with performance or arousal. 20

Specific phobia situational type, is described as a persistent fear that is excessive or unreasonable cued by the presence or anticipation of a specific object or situation such as public transportation, tunnels, bridges, elevators, flying, driving or enclosed places. This subtype has a bimodal age-at-onset distribution with one peak in childhood and another peak in mid-20s. 21

Exposure to the phobic stimulus almost invariably provokes an immediate anxiety response which may take the form of a situational bound or situational predisposed panic attack. The phobic situation usually is avoided or else is endured with intense anxiety or distress. The avoidance interferes often with the person’s normal routine occupational functioning, social activities or relationships. 21 Fear of heights, or acrophobia, is one of the most frequent subtypes of specific phobia frequently associated to depression and other anxiety disorders. 22 It is one of the most prevalent phobias, affecting perhaps 1 in 20 adults. Heights often evoke fear in the general population too, and this suggests that acrophobia might actually represent the hypersensitive manifestation of an everyday, rational fear. 23

From a behavioral perspective, feared situations negatively maintain phobias. Anxiety disorders have been shown to be effectively treated using cognitive behavior therapy (CBT) and therefore to better understand and effectively treat phobias. The CBT model used in the present case, was based on Clark and Wells 24 model that places emphasis on self-focused attention as social anxiety is associated with reduced processing of external social cues. The model pays particular attention to the factors that prevent people, who suffer from social phobias, from changing their negative beliefs about the danger inherent in certain social situations.

The following case it is a good representation of this model.

Case Report

George, was a 23-year-old single, Caucasian male student in his last academic year and was referred to a University Counseling Centre in Athens. The Centre provides free of charge, treatment sessions to all University students requiring psychological support.

George was diagnosed with Social Anxiety Disorder and with Specific phobia, Situational Type i.e . acrophobia. He was living alone in Athens, as his parents live in a different region of Greece. He was an only child. When asked about his childhood, he said that he had been happy and did not report any traumatic events. He described a close relationship with both his parents and when asked, he did not report any family history of psychiatric or psychological disorders or substance abuse problems.

He complained of severe symptoms of anxiety and phobias during the last six months. He began experiencing severe heart palpitations, flushing, fear of fainting and losing control, when travelling by plane, when crossing tall bridges while driving or when being in tall buildings or high places, however he did not experience symptoms of vertigo. Additionally, he reported significant chest pain and muscle tension in feared situations. His fear of experiencing these symptoms worsened and led him to avoid these situations which made his everyday life difficult. He also experienced similar symptoms when introduced to people or meeting people for the first time. He repeatedly went to see various doctors many times in order to exclude any medical conditions. George stated that he didn’t experience any symptoms of depression, had no prior psychological or psychiatric treatment and/or medication, and had first experienced this problem in the course of the previous year.

At the time of the intake, George was in his final exams which he wanted to finish successfully, and continue his studies abroad. Due to his condition, he decided not to apply for a postgraduate degree in the United Kingdom, which he always wanted, and started looking for alternative postgraduate courses in Greece.

Assessment and treatment

George was referred by a private psychiatrist. The psychiatrist used the Mini International Neuropsychiatric Interview, 25 which is a structured interview based on DSM-IV diagnostic criteria. George met the criteria for a Social anxiety disorder. He also met the criteria for specific phobia limited-symptom, which was secondary to his social phobia. The psychiatrist suggested to George, to better help him with his current symptoms to take selective serotonin reuptake inhibitors (SSRIs). George however refused to take any medication and the psychiatrist referred him to the Counseling Centre. For the specific case we decided to give individual cognitive behavior therapy based on Clark and Wells model for Social Anxiety Disorder, 24 as referred into the NICE guidelines. 26 To better assist conceptualization and treatment and also monitor his progress, two therapists were assigned to George and two assessment measures (STAI and SPAI) were given, prior to the course of treatment, following therapy and at one month follow-up. He also had to complete a self-monitoring scale through-out the 20 weeks of treatment.

Monitoring progress measures

State-trait anxiety inventory.

The state-trait anxiety inventory (STAI), 27 the appropriate instrument for measuring anxiety in adults, differentiates between state anxiety , which represents the temporary condition and trait anxiety , which is the general condition. The STAI includes forty questions, with a range of four possible responses. In each of the two subscales scores range from 20 to 80, high scores indicating a high anxiety level. Higher scores correspond to greater anxiety.

Social Phobia and Anxiety Inventory

The Social Phobia and Anxiety Inventory (SPAI) 28 is a 45 item self-report measure that assesses cognition, 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.

George’s pre-treatment scores were, SPAI:126, State Anxiety: 64 and Trait Anxiety: 63. The ultimate goal in each situation was to reduce the client’s level of anxiety.

Cognitive-behavior techniques such as self-monitoring, cognitive restructuring, relaxation, breathing retraining, and assertiveness training were employed to reduce anxiety and fear.

Cognitive behavior therapy techniques

Self-monitoring.

Self-monitoring refers to the systematic observation and recording of one’s own behaviors or experiences on several occasions over a period of time. 29 Self-monitoring can be used as a therapeutic intervention, because it helps the patient to evaluate his/her thoughts, emotions, and behaviors, recognize the feared situations and find appropriate solutions. Kazdin 30 states that self-monitoring can lead to dramatic changes, while Korotitsch and Nelson-Gray 29 add that although the therapeutic effects of self-monitoring may be small, they are rather immediate. George was asked to monitor his thoughts, feelings, and behaviors and record any changes.

George had to complete an Every Day Self-Monitoring Scale for 20 weeks measuring feelings of anxiety (0=no anxiety to 10= most anxiety) and phobia (0=no feelings of phobia to 10=most feelings of phobia), ( Figure 1 ).

Every day self-monitoring scale score.

Cognitive restructuring

Beck and Emery, 19 have identified three phases in cognitive restructuring: i) identification of dysfunctional thoughts ii) modification of dysfunctional thoughts and iii) assimilation of functional thoughts. During cognitive restructuring, the client starts recognizing his/her automatic or dysfunctional thoughts and emotions that derive from this thoughts. For example, one of George’s thoughts was that: it is dangerous to drive at night , which made him feel very anxious and frightened. However, an adaptive thought could be that: that sometimes is dangerous but also a lot of times are not, due the fact that at night there is less traffic in the streets . Therefore, throughout the sessions he was taught how to substitute several automatic negative thoughts with adaptive ones. He also kept a dysfunctional thought record for 6 sessions, which he discussed with his therapist every week.

Muscle relaxation

Relaxation techniques were used for the treatment of George’s symptoms and more specifically for the physiological manifestations of anxiety and panic. 31

George was trained in breathing and muscle relaxation exercises, based on Jacobson’s technique and he was given 8 relaxation training sessions, in order to establish a sense of control over his physical symptoms. The client learned to apply brief muscle relaxation exercises in his daily life and especially every time he had to face an uncomfortable situation.

Assertiveness training

Assertiveness training can be an effective part of treatment for many conditions, such as depression, social anxiety, and problems resulting from unexpressed anger. Assertiveness training can also be useful for those who wish to improve their interpersonal skills and sense of self-respect and it is based on the idea that assertiveness is not inborn, but is a learned behavior. Although some people may seem to be more naturally assertive than others are, anyone can learn to be more assertive. In the specific case the therapists helped George figure out which interpersonal situations are problematic to him and which behaviors need the most attention. In addition, helped to identify beliefs and attitudes the client might had developed, that lead him to become too passive. The therapist used role-playing exercises as part of this assessment.

Clinical sessions

George completed 20 individual, 50 min therapy sessions that took place within a period of 5 months. During the first session the rationale of the cognitive-behavioral treatment was analyzed and special emphasis was given to educate the patient on Social Anxiety disorder and Specific phobias. An introduction was made to the role that automatic thoughts play in our cognitions and helped him to recognize automatic negative thoughts and feelings. A self-monitoring diary of anxiety was given to him as homework. Emphasis was also given to establishing good rapport and collaboration in the therapeutic relationship. During the second session, George narrated stressful life events and reported specific cases in which the anxiety symptoms increased. He was also taught how to identify the three phases of cognitive restructuring and was given the dysfunctional thought record as homework. The third session was based on teaching him breathing exercises and muscle relaxation. Relaxation techniques were taught by a different therapist, with expertise in stress management and relaxation techniques. George was given 8 such sessions, each lasting 20 minutes while he also practiced the sessions daily at home and completed a Daily-form for progress monitoring.

Sessions 4 to 9 were devoted to ways of challenging dysfunctional thoughts by resorting to adaptive responses. At first we tried to recognize negative automatic thoughts during specific situations and record George’s mood in that situation. After recognizing George’s negative thoughts, emotions and behaviors, we worked on the evidence that supported these thoughts.

The next three sessions (10-12) were devoted to teach him assertiveness skills to learn to socialize with people more effectively. We explored what assertiveness meant for George, what prevented him from being assertive and what were the differences between assertive, submissive and aggressive behavior, which he found really helpful and role-playing exercises were initiated to exercise these skills.

Sessions 13-20 were devoted identifying anxiety provoking situations which were hierarchically classified according to the degree of anxiety they produced. An example is shown in Table 1 . Exposure to feared situations was performed by facing in vivo each level of the hierarchy and gradually practice each step, until he was confident enough to go on to the next.

Fear hierarchy for visiting tall buildings.

Accordingly, situations such as driving, crossing bridges etc were also explored.

During the last session, George referred to overcoming challenging experiences, such as meeting new people, visiting friends living in tall apartment buildings and crossing two high bridges, while driving to visit his parents in a different part of Greece. He effectively challenged his cognitions in all relevant situations and utilized muscle relaxation and breathing exercises to control feelings of anxiety. Last session was also devoted to discuss relapse prevention, ways to avoid it and how to overcome past failures and difficulties. Finally, we discussed how he could modify and apply the skills and techniques that he had learned, in his daily routine.

The post-treatment scores of STAI and SPAI obtained by George at termination indicated an improvement. The Social Phobia score dropped to 100, the Anxiety State score was 41 and the Trait score was 42.

During the follow-up session one month later, George talked about his improvement, he mentioned that his progress continued and that he was not experiencing any of the averse symptoms of the past, while driving, visiting tall buildings/bridges and meeting new people. He continued the relaxation and the cognitive restructuring exercises. The STAI & SPAI scales were administered again. The assessment revealed maintenance of gains in terms of reduced anxiety and fear symptoms with State anxiety score: 38, Trait anxiety score: 39 and SPAI score: 77 ( Figure 2 ).

STAI and SPAI Scores.

Treatment implications

In the present clinical case, George attended 20 individual sessions of CBT, in order to reduce his anxiety levels and phobias and learn how to monitor his progress in his daily life. His anxiety levels were reduced in social situations and also he managed to overcome his fear of heights in specific provoking situations. His progress was inevitable which was confirmed by the anxiety scores of the STAI and SPAI. The follow-up session that took place a month later, showed that his progress was sustained. The Every Day Self-Monitoring Scale during the 20 weeks period, showed a gradual reduction in self monitoring feelings of anxiety and phobias ( Figure 1 ).

However although we based our CBT model on Clark and Wells model for Social Anxiety, we had certain variations from the original model. For example, the Clark and Wells model suggests, that individual therapy for social anxiety disorder should consist of up to 14 sessions of 90 minutes’ duration over approximately 4 months. In our case study, the duration of each session lasted 50 minutes and we gave 20 sessions of individual therapy to our client over a period of 5 months, thus trying to tailor our client’s needs and requirements for treatment.

A good rapport was developed with George and that helped the entire treatment process. Working on a list of feared hierarchies in combination with relaxation training skills, George was able to manifest his high level anxiety visiting tall buildings, crossing tall bridges etc. Furthermore, the fact that George learned to identify his automatic thoughts, helped him to reduce his unpleasant feelings by alternating his thoughts. Role-playing exercises in order to acquire assertiveness training skills helped him in relation to meeting new people. It is also worth mentioning that George was motivated and completed his CBT homework every week, something that helped the therapeutic outcome.

Conclusions: recommendations to clinicians and students

Cognitive behavioral therapy is very effective in treating anxiety. It is a structured intervention that follows a general framework that is modified for each individual. For the successful treatment of social phobia, the cognitive behavior therapy must be thorough and comprehensive. Sometimes is needed to use combinations of techniques, like in this case we used traditional CBT techniques in combination with assertiveness skills training. Collaboration with other specialists is also advised for ultimate results, as in this case two therapists were involved, one main therapist and one specialist on stress management techniques. The cognitive-behavior therapist is important to adapt the session, on the basis of his/her client’s needs, for example in the case of George we used exposure based techniques and although the Counseling center offers a maximum of 6 therapeutic sessions, in the case of George we decided on 20 sessions, in order to fully accommodate his problem. It is also very important for the therapist to explain the rationale behind each CBT session and help the patient understand each session’s agenda up to the point he/she feels comfortable to set their own agenda during the session. However, despite the therapist’s best efforts, the patient often hesitates to carry out the everyday homework, thus sometimes delaying the therapeutic progress. Therefore, the good rapport established with the patient will almost certainly add greatly to his/her adherence during the treatment.

Therapist-client relationship, play a fundamental role in the therapy process. It is important for the client to trust the therapist and feel comfortable within the therapy context. Creating a safe and empathetic environment is important from the first therapy session. Furthermore as CBT is directive, a strong therapeutic alliance is necessary to allow the client to feel safe engaging in this type of therapy. It is also important to mention that therapists need to refer to the widely accepted guidelines and recommendations for treating Social anxiety disorders and specific phobias, from widely accepted national institutes, such as the National Institute for Health and Care Excellence that covers both pharmaceutical and psychotherapeutic approaches. However, it is necessary sometimes to tailor-made therapy around client’s needs, as each case must be seen individually . There are too many manuals on CBT and there is the danger for the therapist to work in such a program that can lose creativity, individual thought, imagination and contact with the client. The crucial role of any therapeutic intervention, is not only to help people to acquire the techniques, but to feel comfortable to apply them daily in situations they feel discomfort.

• Presidential Message
• Nominations/Elections
• Past Presidents
• Member Spotlight
• Fellow List
• Fellowship Nominations
• Current Awardees
• Award Nominations
• SCP Mentoring Program
• SCP Book Club
• Pub Fee & Certificate Purchases
• LEAD Program
• Introduction
• Find a Treatment
• Submit Proposal
• Dissemination and Implementation
• Diversity Resources
• Graduate School Applicants
• Student Resources
• Early Career Resources
• Principles for Training in Evidence-Based Psychology
• Advances in Psychotherapy
• Announcements
• Submit Blog
• Student Blog
• The Clinical Psychologist
• CP:SP Journal
• APA Convention
• SCP Conference

CASE STUDY Phil (generalized anxiety disorder)

Case study details.

Phil is a 67-year-old male who reports that his biggest problem is worrying.  He worries all of the time and about “everything under the sun.”  For example, he reports equal worry about his wife who is undergoing treatment for breast cancer and whether he returned his book to the library.  He recognizes that his wife is more important than a book, and is bothered that both cause him similar levels of worry.  Phil is unable to control his worrying.  Accompanying this excessive and uncontrollable worry are difficulty failing asleep, impatience with others, difficulty focusing at work, and significant back and muscle tension.  Phil has had a lifelong problem with worry, recalling that his mother called him a “worry wart.”  His worrying does wax and wane, and worsened when his wife was recently diagnosed with breast cancer.

• Concentration Difficulties
• Irritability
• Sleep Difficulties

Diagnoses and Related Treatments

1. generalized anxiety disorder.

Thank you for supporting the Society of Clinical Psychology. To enhance our membership benefits, we are requesting that members fill out their profile in full. This will help the Division to gather appropriate data to provide you with the best benefits. You will be able to access all other areas of the website, once your profile is submitted. Thank you and please feel free to email the Central Office at  [email protected] if you have any questions

Module 4: Anxiety Disorders

Case studies: examining anxiety, learning objectives.

• Identify anxiety disorders in case studies

Case Study: Jameela

Jameela was a successful lawyer in her 40s who visited a psychiatrist, explaining that for almost a year she had been feeling anxious. She specifically mentioned having a hard time sleeping and concentrating and increased feelings of irritability, fatigue, and even physical symptoms like nausea and diarrhea. She was always worried about forgetting about one of her clients or getting diagnosed with cancer, and in recent months, her anxiety forced her to cut back hours at work. She has no other remarkable medical history or trauma.

For a patient like Jameela, a combination of CBT and medications is often suggested. At first, Jameela was prescribed the benzodiazepine diazepam, but she did not like the side effect of feeling dull. Next, she was prescribed the serotonin-norepinephrine reuptake inhibitor venlafaxine, but first in mild dosages as to monitor side effects. After two weeks, dosages increased from 75 mg/day to 225 mg/day for six months. Jameela’s symptoms resolved after three months, but she continued to take medication for three more months, then slowly reduced the medication amount. She showed no significant anxiety symptoms after one year. [1]

Case Study: Jane

Jane was a three-year-old girl, the youngest of three children of married parents. When Jane was born, she had a congenital heart defect that required multiple surgeries, and she continues to undergo regular follow-up procedures and tests. During her early life, Jane’s parents, especially her mother, was very worried that she would die and spent every minute with Jane. Jane’s mother was her primary caregiver as her father worked full time to support the family and the family needed flexibility to address medical issues for Jane. Jane survived the surgeries and lived a functional life where she was delayed, but met all her motor, communication, and cognitive developmental milestones.

Jane was very attached to her mother. Jane was able to attend daycare and sports classes, like gymnastics without her mother present, but Jane showed great distress if apart from her mother at home. If her mother left her sight (e.g., to use the bathroom), Jane would sob, cry, and try desperately to open the door. If her mother went out and left her with a family member, Jane would fuss, cry, and try to come along, and would continually ask to video-call her, so her mother would have to cut her outings short. Jane also was afraid of doctors’ visits, riding in the car seat, and of walking independently up and down a staircase at home. She would approach new children only with assistance from her mother, and she was too afraid to take part in her gymnastics performances.

Jane also had some mood symptoms possibly related to her medical issues. She would intermittently have days when she was much more clingy, had uncharacteristically low energy, would want to be held, and would say “ow, ow” if put down to stand. She also had difficulty staying asleep and would periodically wake up with respiratory difficulties. [2]

• Bandelow, B., Michaelis, S., & Wedekind, D. (2017). Treatment of anxiety disorders. Dialogues in clinical neuroscience, 19(2), 93–107. ↵
• Hirshfeld-Becker DR, Henin A, Rapoport SJ, et alVery early family-based intervention for anxiety: two case studies with toddlersGeneral Psychiatry 2019;32:e100156. doi: 10.1136/gpsych-2019-100156 ↵
• Modification, adaptation, and original content. Authored by : Margaret Krone for Lumen Learning. Provided by : Lumen Learning. License : CC BY: Attribution
• Treatment of anxiety disorders. Authored by : Borwin Bandelow, Sophie Michaelis, Dirk Wedekind. Provided by : Dialogues in Clinical Neuroscience. Located at : http://Treatment%20of%20anxiety%20disorders . License : CC BY: Attribution

Case-based learning: anxiety disorders

There are many types of anxiety disorders with varying levels of severity. Pharmacists should know the treatment options that are available and how to support patients. 

Shutterstock.com

Anxiety is a common mental health condition that affects approximately 6.6% of the population in England each week, along with one in six adults experiencing or being identified as having a common mental health condition per week [1] , [2] . Data suggest that women are almost twice as likely to be diagnosed with anxiety compared with men; however, the reason for this is unclear [3] , [4] . Although a large number of people are affected by mental health conditions (e.g. anxiety or depression), only 39% of adults aged 16–74 years are accessing treatment for them [5] .

Mental health conditions typically worsen over time and can negatively impact on social activities, relationships, career performance, academic work and general quality of life [6] . As such, patients that present with conditions, such as generalised anxiety disorder (GAD), are frequently seen in the community, with pharmacists having the opportunity to significantly impact on the patient’s quality of life by providing information on the treatment options that are available [7] . While occasional anxiety is a normal aspect of day-to-day life, persistent symptoms can indicate the possible presence of an anxiety disorder, which can often be debilitating. Anxiety has also been known to precipitate physiological responses, such as tachycardia and hyperhidrosis [8] . ’Functional impairment’ is a term that is often used to describe the degree to which an illness can limit a person’s ability to carry out some of their normal daily tasks; anxiety can affect this to differing degrees [9] .

There are multiple factors that could predispose or potentially encourage the manifestation of anxiety, which are often attributable to a combination of genetic and environmental factors [10] . In addition, studies suggest that alcohol and illicit drug use, particularly the use of stimulants and hallucinogens, are associated with higher rates of incidence [11] , [12] . Instances of childhood abuse and sexual abuse are also identified as potential causative factors for anxiety and depression [13] . However, there is a broad range of patients affected by anxiety, for whom there is often an unknown cause.

Types of anxiety

Anxiety disorder is an inclusive term for several disorders, including:

• Panic disorder;
• Selective mutism;
• Separation anxiety;
• Social anxiety disorder [14] .

The most common types of anxiety disorder include:

• Social anxiety disorder — this is considered to be the most common form of anxiety; in up to 50% of cases, it is present in individuals by age 11 years [15] . Symptoms include a persistent fear of social performance, panic attacks and a large fear of humiliating oneself in public [15] ;
• Phobic disorder — this broadly refers to a fear of places, situations, objects and animals. For example, agoraphobia is often considered to be simply a fear of open spaces, but it is far more serious and can include a fear of being in a place that individuals will find difficult to escape from or receive aid if things go wrong [16] .

Avoidance behaviour is common to both social anxiety disorder and phobic disorder, with patients actively trying not to encounter the feared stimulus (e.g. avoiding going outside, such as in cases of agoraphobia) [17] , [18] , [19] . This behaviour can hugely impact on a patient’s ability to maintain functional capacity.

Symptoms and diagnosis

Symptoms may involve feelings of restlessness, palpitations, problems with concentrating, uncontrollable worry, sleep disturbances and general irritability [6] .

Diagnosis of anxiety would initially be made by a GP following a comprehensive review of the following:

• Symptomatic presentation of the patient;
• Frequency of symptoms;
• Degree of severity of distress;
• Functional impairment.

History of substance misuse, comorbidities and past medical history should be considered as part of a holistic approach to diagnosis [20] .

In addition, differential diagnoses must be considered before a formal diagnosis is made. Anaemia and hyperthyroidism are two conditions that must be ruled out and/or treated as they can both manifest symptoms of anxiety disorders [21] , [22] . Blood analysis and further tests may be necessary to ensure a correct diagnosis is made [22] , [23] . As stated by the National Institute for Health and Care Excellence (NICE), diagnostic tools, such as the Diagnostic and Statistical Manual of Mental Disorders , can be utilised for anxiety disorders [21] . The criteria include a minimum of six months of incessant and uncontrollable worries, disproportionate to actual risk, and three of the following symptoms:

• Being easily fatigued;
• Irritability;
• Muscle tension;
• Poor concentration;
• Restlessness/nervousness;
• Sleep disturbance [21] .

The ‘International Classification of Diseases, 10th revision’, a disease classification tool, offers a similar criteria [21] . There are also other resources available to healthcare professionals to work through with patients, such as the GAD-7 questionnaire for anxiety and the personal health questionnaire-9 (PHQ-9) for depression [21] . Questions typically ask how frequently certain symptoms have occurred in the preceding two weeks. Both GAD-7 and PHQ-9 allow assessors to distinguish between anxiety and depression, and provide an indication as to the severity of presentation, which can guide therapy. These are typically asked by a GP during an initial consultation with the patient and may include questions such as: ‘Over the past two weeks, how often have you been bothered by feeling nervous, anxious or on edge?’ [24]

The GAD-7 questionnaire can also be used as a tool to determine the severity of its presentation, with scores of 5 and above, 10 and above, and 15 and above (out of a possible 21) referring to mild, moderate and severe anxiety, respectively [25] . Higher scores are strongly associated with functional impairment, although individual characteristics of presentation will affect how the patient is treated.

Pharmacological treatment

For patients with mild anxiety, pharmacotherapy is not recommended. However, as per NICE guidelines, pharmacological treatment is recommended where significant functional impairment exists [26] . First-line drug treatment involves selective serotonin reuptake inhibitors (SSRIs; e.g. sertraline or fluoxetine) [26] .

SSRIs are widely used for GAD and are often well tolerated. In addition, they are considered to be safer in overdose than most other similarly indicated medicines, because they carry a lower risk of cardiac conduction abnormalities and seizures [27] , [28] , [29] . Selective serotonin–noradrenaline reuptake inhibitors (SNRIs; e.g. duloxetine and mirtazapine) are a suitable alternative; pregabalin is a tertiary option if the others are unsuitable or poorly tolerated [26] .

It is important to manage the patients’ expectations with pharmacological therapies. Providing a clear message that it could take between four and six weeks before the patient notices a benefit from their medicine is essential, as this will help ensure that they take their medication as directed. Patients should also be made aware of side effects and the withdrawal process (e.g. associated side effects) prior to commencing therapy [26] .

Common side effects of SSRIs include abnormal appetite, arrhythmias, impaired concentration, confusion, gastrointestinal discomfort and sleep disorders [27] . The incidence of side effects is reported to be highest within the first two weeks of starting treatment [30] . Although most common side effects tend to improve over time, sexual dysfunction can persist [31] . There is an increased risk with SSRIs in certain patient groups (e.g. young adults, children and patients with a previous history of suicidal behaviour) of suicidal ideation and self-harm; therefore, initiation of SSRIs must be reviewed weekly in those under aged under 30 years for the first four weeks of treatment. If the risk of recurrent suicidal behaviour is a concern, the healthcare professional may want to seek advice from the local crisis or home-based treatment team; SSRIs generally have a better safety profile than other drugs used for anxiety, but may require frequent monitoring in this case [32] , [26] .

SSRIs are one of several classes of medicines that pose a risk for long QT syndrome, which occurs as a result of a prolonged QT interval on the electrocardiogram measurements of the heart. This can lead to torsades de pointes (a specific type of abnormal heart rhythm) and possible sudden cardiac death [33] [34] , [35] .

It is important that SSRIs are withdrawn slowly to minimise the occurrence of SSRI discontinuation syndrome — an abrupt cessation of treatment that can cause a combination of psychological and physiological symptoms; the most common including nausea, dizziness, headache and lethargy [36] . Tapering drug doses slowly over several weeks will mitigate the effects of the withdrawal and minimise unnecessary re-initiation of the SSRI [37] .

Considerations for selective serotonin reuptake inhibitors and selective serotonin–noradrenaline reuptake inhibitors

Serotonin syndrome is a serious side effect that can occur with the use of SSRIs and SNRIs. It occurs as a result of overactivation of the 5-HT1A and 5-HT2A receptors, precipitated by serotonergic drug use [38] . Symptoms typically range from confusion and agitation to more serious symptoms, such as seizures, arrhythmias and loss of consciousness [31] . The risk of the syndrome is higher if patients are taking other medicines that can increase serotonin levels in the brain, such as tramadol and metoclopramide. Taking 5-HT1F agonists, which include sumatriptan, or a combination of medicines with the same effect, can also increase risk [39] .

If a decision is made to initiate an SSRI, despite the associated risk, patients should be provided with suitable information concerning the syndrome, which can be found on or printed from the NHS website [31] . If a patient experiences symptoms of serotonin sydrome, they should be advised to contact their GP surgery immediately. If this is unavailable, they should call NHS 111 for advice.

Alongside serotonin syndrome, SSRIs have been known to contribute to inappropriate antidiuretic hormone secretion, which is related to hyponatremia and has symptoms including headache, insomnia, nervousness and agitation [40] . 

Patients with anxiety disorders should be monitored as frequently as the severity of the disorder demands, which is essential to protect patients and improve their quality of life. Guidance from the British National Formulary states that patients being initiated on an SSRI should be reviewed every one to two weeks after initiation, with response being assessed at four weeks to determine whether continuation of the drug is suitable [27] . NICE guidelines expand on this by encouraging three-monthly reviews of drug therapy to assess clinical effectiveness [20] .

Non-pharmacological treatment

Patients should be advised to minimise alcohol intake and make time for activities they find relaxing. They should also be encouraged to exercise every day, aiming to do 150 minutes of moderate-intensity exercise (e.g. walking or cycling) per week as exercising has been shown to improve mental health [41] , [42] . A study has demonstrated that those who exercise had 43.2% fewer days of poor mental health, with team sports having the largest association with reduction in mental health burden [43] .

Psychological treatment

Cognitive behavioural therapy (CBT) is a common psychological treatment used for those with anxiety. This therapy aims to transform negative thinking into more structured thought patterns, which then assist the patient in making changes to their thought processes to encourage positive thinking. CBT is suitable for patients that present with ongoing anxiety and does not look at patient history [34] . This type of treatment may be useful for patients with mild anxiety, as an addition to medicine or for those who do not wish to take medicine. It can be conducted individually or as part of a group.

Guided self-help — a process by which a patient is able to work through a course with the support of a trained therapist — and counselling are other treatments available through the NHS that may benefit patients with mild anxiety or as an adjunct to prescription medicines [44] .

Specialist referral and suicide risk

Specialist referral should be considered if patients:

• Have not responded to initial therapy;
• Have comorbidities, such as alcohol or substance misuse;
• Are at significant suicide risk.

Healthcare professionals should always assess suicide risk by discussing the patients’ feelings about self-harm openly and considering other contributing factors, such as the use of prescribed or illicit drugs. Healthcare professionals must take opportunities to make interventions — for example, referring patients for urgent mental health assessment or in the case of serious concerns, calling emergency services [23] .

In the UK, area-specific community programmes and the charity  Anxiety UK  can provide patients with further advice on managing their anxiety. However, many primary care networks are now recruiting social prescribers, who will have the ability to direct patients to attend local groups that are more suited to individual needs. Community pharmacists are also likely to be aware of local support networks.

Case studies

Case study 1: a woman taking interacting medicines

Joanne*, a woman aged 65 years, approaches the pharmacy counter. She is concerned about heart palpitations she has been experiencing recently.

After inviting Joanne into the consultation room, you ask her if she is taking any medicines. She says that she is taking amitriptyline for the pain in her legs. She has also recently started taking a new medicine and states that she is on other medicines, but cannot recall the names. You ask for permission to view her summary care record and note that there is furosemide on her list of medicines. She was started on citalopram two weeks prior and was prescribed a seven-day course of clarithromycin three days ago.

You are concerned that Joanne is experiencing long QT syndrome, since the selective serotonin reuptake inhibitor (SSRI) citalopram is a risk factor for QT prolongation — as are the tricyclic antidepressant amitriptyline and the antibiotic clarithromycin [33] , [45] , [46] . In addition, furosemide can also precipitate hypokalaemia, which has been known to affect the QT interval [47] .

Advice and recommendations

You advise Joanne to stop taking the citalopram that has been prescribed to her until she can see a GP, which is a matter of urgency, as you believe it could be related to the medicines she is taking. You advise that she should try and get a same-day appointment if possible. The GP will likely request an electrocardiogram and stop the SSRI if results demonstrate long QT syndrome.

Case study 2: a man with concerns about his medicine

Gareth*, an investment banker aged 52 years, attends the pharmacy and asks to purchase sildenafil over the counter, owing to his erectile dysfunction. He is referred to you and you sit with him in the consultation room.

During the consultation, you begin to ask questions about his history and whether the erectile dysfunction is a new condition that he is experiencing. He states that he has been worried about it for the last couple of months. You then discuss his lifestyle and ask him questions about his medicines, in which he states he started taking a new medicine, fluoxetine, several months ago. He has been under significant stress at his workplace and was started on fluoxetine owing to his anxiety.

You consider the following:

• The erectile dysfunction that Gareth is experiencing could be related to the stress he is experiencing as part of his work;
• The possibility there could be an underlying reason for the problem related to his general health;
• That the prescribed fluoxetine may be causing his erectile dysfunction because this is a side effect of selective serotonin reuptake inhibitors [48] .

You explain your rationale with Gareth and indicate that you do not think it is appropriate to sell him sildenafil now. You suggest he goes back to his GP to discuss the symptoms that he has been having. The GP may decide to try an alternative medicine, but, given that he has been taking the fluoxetine for a few months, he should not discontinue it until advised to do so by his GP. You explain that if his GP advises him to stop the medicine, there will be a specific withdrawal process to minimise the side effects and that you would be able to advise him on this.

Case study 3: a man who is displaying symptoms of moderate anxiety

Anton*, a university graduate aged 21 years, attends the pharmacy and asks to speak to the pharmacist in private. He states he is worried about heart palpitations that he has been experiencing. He is visibly sweating and looks on edge.

You invite Anton into the consultation room and ask him about his symptoms. He states that he has started a new job and that the palpitations start when he is feeling anxious. His symptoms are occurring most days of the week and he says it makes him “feel on edge”. He adds that he does not want to socialise with his co-workers. It is starting to affect his sleep and he does not know what to do. He also states that he has occasional pain in his chest.

Treatment options

Anton is demonstrating symptoms of moderate anxiety, given his desire to avoid socialising, and has a degree of functional impairment. However, as he has potential cardiac symptoms, these issues could be related to another condition.

When questioned, he confirms he has no other problems with his health, but you feel the patient needs further investigation — for example, an electrocardiogram test to measure the electrical activity of his heart to rule out underlying cardiac problems. His presentation concerns you and you feel he needs to see a doctor today to assess the differential diagnosis, as you are worried about his chest pain and palpitations.

You encourage Anton by saying that it is great that he felt he could talk to a pharmacist about this, but explain that he would benefit from a consultation with a GP. You explain that his symptoms could be related to anxiety and that you think he may need something to help him manage. He agrees to let you contact his local practice. As you have a good relationship with the practice, you manage to secure an appointment for him to see a GP that day. If a GP appointment had been unavailable, you could have telephoned NHS 111 for Anton to seek access to support.

*All cases are fictional

Useful resources

• NHS: Do I have an anxiety disorder?

[1] Fineberg NA, Haddad PM, Carpenter L et al . The size, burden and cost of disorders of the brain in the UK. J Psychopharmacol 2013;27(9):761–770. doi: 10.1177/0269881113495118

[2] Anxiety UK. Frequently asked questions. 2018. Available at: https://www.anxietyuk.org.uk/get-help/anxiety-information/frequently-asked-questions/ (accessed May 2020)

[3] No Panic. Anxiety statistics. 2018. Available at: https://nopanic.org.uk/anxiety-statistics/ (accessed May 2020)

[4] NHS England. Women are more likely to suffer from anxiety than men. 2016. Available at: https://www.nhs.uk/news/mental-health/women-are-more-likely-to-suffer-from-anxiety-than-men/ (accessed May 2020)

[5] NHS Digital. Adult psychiatric morbidity survey: Survey of mental health and wellbeing, England 2014. 2014. Available at: https://digital.nhs.uk/data-and-information/publications/statistical/adult-psychiatric-morbidity-survey/adult-psychiatric-morbidity-survey-survey-of-mental-health-and-wellbeing-england-2014 (accessed May 2020) 

[6] National Institute of Mental Health. Anxiety disorders. 2018. Available at: https://www.nimh.nih.gov/health/topics/anxiety-disorders/index.shtml (accessed May 2020)

[7] Braga SFF, Clark KJ & Shirer AE. US Pharm.  An overview of generalized anxiety disorder for the community pharmacist. 2019. Available at:  https://www.uspharmacist.com/article/an-overview-of-generalized-anxiety-disorder-for-the-community-pharmacist (accessed May 2020)

[8] McLeod DR, Hoehn-Daric R & Stefan RL. Somatic symptoms of anxiety: comparison of self-report and physiological measures. Biol Psychiatry 1986;21(3):301–310. doi: 10.1016/0006-3223(86)90051-x

[9] Ustün B & Kennedy C. What is “functional impairment”? Disentangling disability from clinical significance. World Psychiatry 2009;8(2):82–85. doi: 10.1002/j.2051-5545.2009.tb00219.x

[10] Durbano F.  A Fresh Look at Anxiety Disorders . InTech: Croatia; 2015

[11] Schuckit MA & Hesselbrock V. Alcohol dependence and anxiety disorders. Focus 2004;2(3):440–453. doi: 10.1176/foc.2.3.440

[12] Sareen J, Chartier M, Paulus MP & Stein MB. Illicit drug use and anxiety disorders: findings from two community surveys. Psychiatry Res 2006;142(1):11–17. doi: 10.1016/j.psychres.2006.01.009

[13] Mancini C, Van Ameringen M & MacMillan H. Relationship of childhood sexual and physical abuse to anxiety disorders. J Nerv Men Dis 1995;183(5):309–314. doi: 10.1097/00005053-199505000-00006

[14] Anxiety and Depression Association of America. Understanding the facts of anxiety disorders and depression is the first step. 2020. Available at: https://adaa.org/understanding-anxiety (accessed May 2020)

[15] Stein MB & Stein DJ. Social anxiety disorder. Lancet 2008;371(9618):1115–1125. doi: 10.1016/S0140-6736(08)60488-2

[16] Marks I. Fears, Phobias and Rituals: Panic, Anxiety and Their Disorders . Oxford University Press: New York; 1987.

[17] NHS. Phobias. 2018. Available at: https://www.nhs.uk/conditions/phobias/ (accessed May 2020)

[18] Hofmann S & DiBartolo P. Social Anxiety: Clinical, developmental and social perspectives . 3rd edn. Academic Press: San Diego; 2014.

[19] Marks I. Fears and Phobias . Academic Press: New York; 1969.

[20] National Institute for Health and Care Excellence. Generalised anxiety disorder and panic disorder in adults: management. Clinical guideline [CG113]. 2011. Available at: https://www.nice.org.uk/guidance/cg113/resources/generalised-anxiety-disorder-and-panic-disorder-in-adults-management-35109387756997 (accessed May 2020)

[21] National Institute for Health and Care Excellence. NICE Pathways. Generalised anxiety disorder. 2019. Available at: https://pathways.nice.org.uk/pathways/generalised-anxiety-disorder (accessed May 2020)

[22] British Thyroid Foundation. Hyperthyroidism. 2018. Available at: https://www.btf-thyroid.org/hyperthyroidism-leaflet (accessed May 2020)

[23] NHS. Generalised anxiety disorder in adults. 2018. Available at: https://www.nhs.uk/conditions/generalised-anxiety-disorder/ (accessed May 2020)

[24] National Institute for Health and Care Excellence. Clinical knowledge summaries. Generalized anxiety disorder. 2017. Available at: https://cks.nice.org.uk/generalized-anxiety-disorder (accessed May 2020)

[25] Spitzer RL, Kroenke K, Williams JB & Lowe B. A brief measure for assessing generalized anxiety disorder. Arch Intern Med . 2006;166:1092–1097. doi: 10.1001/archinte.166.10.1092

[26] National Institute for Health and Care Excellence. Generalized anxiety disorder. Scenario: management of a person with generalized anxiety. 2017. Available at:  https://cks.nice.org.uk/generalized-anxiety-disorder#!scenario (accessed May 2020)

[27] British National Formulary. 2020. Available at: https://bnf.nice.org.uk/ (accessed May 2020)

[28] Ferguson JM. SSRI Antidepressant medications: adverse effects and tolerability. Prim Care Companion J Clinl Psychiatry 2001;3(1):22–27. doi: 10.4088/pcc.v03n0105

[29] Yekehtaz H, Farokhnia M & Akhondzadeh S. Cardiovascular considerations in antidepressant therapy. J Tehran Heart Cent 2013;8(4):169–176. PMID: 260058484

[30] Warden D, Trivedi MH, Wisniewski SR et al. Early adverse events and attrition in selective serotonin reuptake inhibitor treatment: a suicide assessment methodology study report. J Clin Psychopharmacology 2010;30(3):259–266. doi: 10.1097/JCP.0b013e3181dbfd04

[31] NHS. Antidepressants. 2018. Available at: https://www.nhs.uk/conditions/antidepressants/ (accessed May 2020)

[32] National Institute for Health and Care Excellence. Antidepressant drugs. 2020. Available at: https://bnf.nice.org.uk/treatment-summary/antidepressant-drugs.html

[33] Funk KA & Bostwick JR. A comparison of the risk of QT prolongation among SSRIs. Ann Pharmacother 2013;47(10): 1330-1341. doi: 10.1177/1060028013501994

[34] Kannankeril PJ & Roden DM. Drug-induced long QT and torsade de pointes: recent advances. Curr Opin Cardio 2007;22(1):39–43. doi: 10.1097/HCO.0b013e32801129eb

[35] Yap YG & Camm AJ. Drug induced QT prolongation and torsades de pointes . Heart  2003;89(11):1363–1372. doi: 10.1136/heart.89.11.1363

[36] Haddad P. The SSRI discontinuation syndrome.  J Psychopharmacol 1998;12(3): 305–313. doi: 10.1177/026988119801200311

[37] Horowitz M & Taylor D. Tapering of SSRI treatment to mitigate withdrawal symptoms. Lancet Psychiatry .  2019;6:538–546.  doi: 10.1016/S2215-0366(19)30032-X

[38] Volpi-Abadie J, Kaye AM & Kaye AD. Serotonin Syndrome. Ochsner J 2013;13(4):533–540. PMID: 24358002

[39] Specialist Pharmacy Service. What is serotonin syndrome and which medicines cause it? 2020. Available at: https://www.sps.nhs.uk/articles/what-is-serotonin-syndrome-and-which-medicines-cause-it-2/ (accessed May 2020)

[40] Kirpekar VC & Joshi PP. Syndrome of inappropriate ADH secretion (SIADH) associated with citalopram use. Indian J Psychiatry 2005;47(2):119–120. doi: 10.4103/0019-5545.55960

[41] NHS. Get fit for free. 2019. Available at: https://www.nhs.uk/live-well/exercise/free-fitness-ideas/ (accessed May 2020)

[42] Anxiety UK. Physical Exercise & Anxiety. 2018. Available at: https://www.anxietyuk.org.uk/get-help/anxiety-information/physical-exercise-anxiety/ (accessed May 2020) 

[43] Chekroud SG, Gueorguieve R, Zheutlin AB et al . Association between physical exercise and mental health in 1.2 million individuals in the USA between 2011 and 2015: a cross-sectional study.  Lancet Psychiatry 2018;5(9):739–746. doi: 10.1016/S2215-0366(18)30227-X

[44] NHS. Types of talking therapies. 2018. Available at: https://www.nhs.uk/conditions/stress-anxiety-depression/types-of-therapy/ (accessed May 2020)

[45] Vieweg WV & Wood MA. Tricyclic Antidepressants, QT interval prolongation and torsade de pointes. Psychosomatics 2004;45(5):371–377. doi: 10.1176/appi.psy.45.5.371

[46] Kamochi H, Nii T, Eguchi K et al . Clarithromycin associated with torsades de pointes . Jpn Circ J 1999;63:421–422.  doi: 10.1253/jcj.63.421

[47] Snitker S, Doerfier RM, Soliman EZ et al . Association of QT-prolonging medication use in CKD with electrocardiographic manifestations. Clin J Am Soc Nephrol 2017;12(9):1409–1417. doi: 10.2215/CJN.12991216

[48] Montejo-Gonzalez AL, Llorca G, Izguierdo JA et al . SSRI-induced sexual dysfunction: fluoxetine, paroxetine, sertraline and fluvoxamine in a prospective, multicentre and descriptive clinical study of 344 patients. J Sex Marital Ther 1997;23(3):176–194. doi: 10.1080/00926239708403923

You might also be interested in…

Nearly half of long-term antidepressant users could safely taper off medication using helpline

Boots UK shuts online mental health service to new patients

Eating disorders: identification, treatment and support

Transforming the understanding and treatment of mental illnesses.

Información en español

Celebrating 75 Years! Learn More >>

• Health Topics
• Brochures and Fact Sheets
• Help for Mental Illnesses
• Clinical Trials

Substance Use and Co-Occurring Mental Disorders

What does it mean to have substance use and co-occurring mental disorders.

Substance use disorder (SUD) is a treatable mental disorder that affects a person’s brain and behavior, leading to their inability to control their use of substances like legal or illegal drugs, alcohol, or medications. Symptoms can be moderate to severe, with addiction being the most severe form of SUD.

People with a SUD may also have other mental health disorders, and people with mental health disorders may also struggle with substance use. These other mental health disorders can include anxiety disorders , depression , attention-deficit hyperactivity disorder (ADHD) , bipolar disorder , personality disorders , and schizophrenia , among others. For more information, please see the National Institute on Drug Abuse (NIDA)  Common Comorbidities with Substance Use Disorders Research Report  .

Though people might have both a SUD and a mental disorder, that does not mean that one caused the other. Research suggests three possibilities that could explain why SUDs and other mental disorders may occur together:

• Common risk factors can contribute to both SUDs and other mental disorders. Both SUDs and other mental disorders can run in families, meaning certain genes may be a risk factor. Environmental factors, such as stress or trauma, can cause genetic changes that are passed down through generations and may contribute to the development of a mental disorder or a substance use disorder.
• Mental disorders can contribute to substance use and SUDs. Studies found that people with a mental disorder, such as anxiety, depression, or post-traumatic stress disorder (PTSD) , may use drugs or alcohol as a form of self-medication. However, although some drugs may temporarily help with some symptoms of mental disorders, they may make the symptoms worse over time. Additionally, brain changes in people with mental disorders may enhance the rewarding effects of substances, making it more likely they will continue to use the substance.
• Substance use and SUDs can contribute to the development of other mental disorders. Substance use may trigger changes in brain structure and function that make a person more likely to develop a mental disorder.

How are substance use disorder and co-occurring mental disorders diagnosed and treated?

When someone has a SUD and another mental health disorder, it is usually better to treat them at the same time rather than separately. People who need help for a SUD and other mental disorders should see a health care provider for each disorder. It can be challenging to make an accurate diagnosis because some symptoms are the same for both disorders, so the provider should use comprehensive assessment tools to reduce the chance of a missed diagnosis and provide the right treatment.

It also is essential that the provider tailor treatment, which may include behavioral therapies and medications, to an individual’s specific combination of disorders and symptoms. It should also take into account the person’s age, the misused substance, and the specific mental disorder(s). Talk to your health care provider to determine what treatment may be best for you and give the treatment time to work.

Behavioral therapies

Research has found several behavioral therapies that have promise for treating individuals with co-occurring substance use and mental disorders. Health care providers may recommend behavioral therapies alone or in combination with medications.

Some examples of effective behavioral therapies for adults with SUDs and different co-occurring mental disorders include:

• Cognitive behavioral therapy (CBT) is a type of talk therapy  aimed at helping people learn how to cope with difficult situations by challenging irrational thoughts and changing behaviors.
• Dialectical behavior therapy (DBT) uses concepts of mindfulness and acceptance or being aware of and attentive to the current situation and emotional state. DBT also teaches skills that can help control intense emotions, reduce self-destructive behaviors (such as suicide attempts, thoughts, or urges; self-harm; and drug use), and improve relationships.
• Assertive community treatment (ACT) is a form of community-based mental health care that emphasizes outreach to the community and an individualized treatment approach.
• Therapeutic communities (TC)    are a common form of long-term residential treatment that focuses on helping people develop new and healthier values, attitudes, and behaviors.
• Contingency management (CM) principles encourage healthy behaviors by offering vouchers or rewards for desired behaviors.

Behavioral therapies for children and adolescents

Some effective behavioral treatments for children and adolescents include:

• Brief strategic family therapy (BSFT) therapy targets family interactions thought to maintain or worsen adolescent SUDs and other co-occurring problem behaviors.
• Multidimensional family therapy (MDFT) works with the whole family to simultaneously address multiple and interacting adolescent problem behaviors, such as substance use, mental disorders, school problems, delinquency, and others.
• Multisystemic therapy (MST) targets key factors associated with serious antisocial behavior in children and adolescents with SUDs.

Medications

There are effective medications that treat opioid  , alcohol  , and nicotine addiction  and lessen the symptoms of many other mental disorders. Some medications may be useful in treating multiple disorders. For more information on behavioral treatments and medications for SUDs, visit NIDA’s Drug Facts  and Treatment  webpages. For more information about treatment for mental disorders, visit NIMH's Health Topics webpages.

How can I find help for substance use and co-occurring mental disorders?

To find mental health treatment services in your area, call the Substance Abuse and Mental Health Services Administration (SAMHSA) National Helpline at 1-800-662-HELP (4357), visit the SAMHSA online treatment locator  , or text your ZIP code to 435748.

For additional resources about finding help, visit:

NIMH's Help for Mental Illnesses page

National Cancer Institute’s Smokefree.gov  website, or call their smoking quitline at 1-877-44U-QUIT (1-877-448-7848)

If you or someone you know is struggling or having thoughts of suicide, call or text the 988 Suicide & Crisis Lifeline   at 988 or chat at 988lifeline.org   . In life-threatening situations, call 911.

How can I find a clinical trial for substance use and co-occurring mental disorders?

Clinical trials are research studies that look at new ways to prevent, detect, or treat diseases and conditions. The goal of clinical trials is to determine if a new test or treatment works and is safe. Although individuals may benefit from being part of a clinical trial, participants should be aware that the primary purpose of a clinical trial is to gain new scientific knowledge so that others may be better helped in the future.

Researchers at NIMH and around the country conduct many studies with patients and healthy volunteers. We have new and better treatment options today because of what clinical trials uncovered years ago. Be part of tomorrow’s medical breakthroughs. Talk to your health care provider about clinical trials, their benefits and risks, and whether one is right for you.

To learn more or find a study, visit:

• NIMH’s Clinical Trials webpage : Information about participating in clinical trials related to mental disorders
• Clinicaltrials.gov: Current studies on mental illness and substance misuse  : List of clinical trials funded by the National Institutes of Health (NIH) being conducted across the country

Where can I learn more about substance use and co-occurring disorders?

Brochures and other educational resources.

• National Institute on Alcohol Abuse and Alcoholism (NIAAA) Publications Order Form 
• NIDA: Parents and Educators 
• SAMHSA Publications and Digital Products 
• Alcohol Use Disorder  (also en español  )
• Drug Use and Addiction  (also en español  )
• Mental Health and Behavior  (also en español  )
• Opioids and Opioid Use Disorder   (also en español  )
• Risks of tobacco   (also en  español  )
• NIH Experts Discuss the Intersection of Suicide and Substance Use : Learn about common risk factors, populations at elevated risk, suicides by drug overdose, treatments, prevention, and resources for finding help.
• NIDA Common Physical and Mental Health Comorbidities with Substance Use Disorders Research Report 
• NIDA Tobacco, Nicotine, and E-Cigarettes Research Report 
• SAMHSA National Survey on Drug Use and Health 
• Suicide Deaths Are a Major Component of the Opioid Crisis that Must Be Addressed
• NIMH and the NIH HEAL Initiative: Collaborating to address the opioid epidemic
• NIMH’s Role in the NIH HEAL Initiative

Last reviewed: March 2024

Unless otherwise specified, the information on our website and in our publications is in the public domain and may be reused or copied without permission. However, you may not reuse or copy images. Please cite the National Institute of Mental Health as the source. Read our copyright policy to learn more about our guidelines for reusing NIMH content.