Social anxiety disorder
First-year college student avoiding classes, presentations, and dining halls; LSAS at 84.
Presenting concern
Referred by college counseling center. LSAS: 84 (severe). Skipping classes with mandatory participation, eating in dorm room, declining social invitations. Pre-event rumination and post-event analysis dominate his week.
History
Shy child, escalating to avoidance starting middle school. No prior treatment. Move to college removed accommodations parents had built. Mild depressive symptoms secondary to isolation.
- Academic failure if avoidance continues
- Secondary depression brewing
- Limited social network in new environment
- Family far away
- First treatment episode
- High academic motivation
- Self-referred (technically — accepted the referral readily)
- No comorbid substance use
Conceptualization across modalities
Self-focused attention plus negative self-image in social situations plus safety behaviors (looking down, rehearsing sentences, drinking water to avoid speaking) prevent disconfirmation. Pre- and post-event processing inflate threat. Core belief: 'I'm fundamentally weird/incompetent and others will see it.'
- Video feedback to challenge self-image
- Dropping safety behaviors in exposures
- Attention training away from self
- Behavioral experiments testing social predictions
Treatment plan
Engage (1–2)
Formulation, psychoed, hierarchy.
Skills + early exposures (3–8)
Attention training, low-rung in vivo exposures with safety-behavior drops.
Harder exposures (9–14)
Class participation, presentations, dining hall meals.
Consolidate (15–18)
Generalize, reduce post-event processing, plan summer.
LSAS dropped to 42 by session 16. Joined one student club by session 12 (huge clinical milestone).