57 Social Phobia (Social Anxiety Disorder)

Name: Barry Egan

Source: Punch-Drunk Love (movie, 2002)

Background Information

Barry Egan is a Caucasian male in his early to mid-forties who lives alone in an apartment in Los Angeles, California. He is the owner of a small business that sells novelty items. Barry is not suffering from any known medical conditions or other health problems, but appears to have some mental health concerns. He is easily provoked into violent tantrums in which he punches walls, breaks windows, or destroys others personal property. He does not appear to have any alcohol or drug dependencies; in fact, he appears to drink alcohol very minimally. Barry has seven sisters, all of whom are very domineering and verbally abusive to him. Barry’s sisters have tormented and ridiculed him since childhood. As an adult, his sisters are still very controlling of his life and continue to torment him with embarrassing stories from his childhood. Barry has difficulty with personal relationships and appears to be lonely. His goals include growing his business. His hobbies include finding unbelievably good deals and repairing and learning to play the harmonium. Barry can be rather naïve and trusting of others, which leads to being taken advantage of and making poor financial decisions.

Description of the Problem

Barry is currently seeking help because he feels something might be wrong and states that he “doesn’t like himself,” but is unsure if this is abnormal since he is uncertain how other people are. He states that he “cries a lot.” Barry can be described as a socially awkward individual who does not seek out or actively engage in social activity with others. It appears that Barry has little to no family support system and that his relationship with his seven sisters relates to his low self-esteem. He constantly apologizes for things even when he did not do anything wrong, and stumbles with his speech by merging words together. Barry becomes very anxious in social situations. He endures these situations with intense anxiety and distress, which sometimes can lead to a panic attack following the interaction. Barry has a tendency to become violent when provoked with embarrassing stories from his childhood. He is known to lie and deny his actions when confronted. Barry is currently in a relationship with a woman he recently met. The relationship appears to be a positive factor in Barry’s life.

Diagnosis

The diagnosis for Barry Egan is Social Phobia (300.23). According to the DSM-IV-TR the following criteria are met:

1. A marked and persistent fear of one or more social or performance situations in which the person is exposed to unfamiliar people or to possible scrutiny by others. The individual fears that he or she will act in a way (or show anxiety symptoms) that will be humiliating or embarrassing. NOTE: In children, there must be evidence of the capacity for age-appropriate social relationships with familiar people and the anxiety must occur in peer settings, not just in interactions with adults.
   • Barry shows fear in meeting new people or encountering people in unexpected situations. He showed this in several situations; for example, when he met Lena for the first time he was obviously uncomfortable and showing signs of fear and while at his sister’s house he also showed a marked fear of scrutiny from his sisters.
2. Exposure to the feared social situation almost invariably provokes anxiety, which may take the form of a situationally bound or situationally predisposed panic attack. NOTE: In children, the anxiety may be expressed by crying, tantrums, freezing, or shrinking from social situations with unfamiliar people.
   • Barry’s reaction to his sisters demoralizing remarks about him from the other room was a panic attack that took the form of Barry kicking out the glass at his sister’s house.
3. The person recognizes that the fear is excessive or unreasonable. NOTE: In children, this feature may be absent.
   • Barry did not know exactly what was wrong with himself, but his attempt to reach out to his brother-in-law showed that he knew that something was unreasonable and that he needed help.
4. The feared social or performance situations are avoided or else endured with intense anxiety or distress.
   • Barry avoided meeting Lena at his sister’s house as best he could. When his sister brought Lena to his work to introduce the two, he was extremely anxious and distressed. He started fumbling all over the place, unable to perform his job and having a hard time communicating with Lena and his sister.
5. The avoidance, anxious anticipation, or distress in the feared social or performance situation(s) interferes significantly with the person’s normal routine, occupational (academic) functioning, or social activities or relationships, or there is marked distress about having the phobia.
   • Barry lived his life without much interaction with others before meeting Lena. Although he was lonely, he did not have the ability to initiate healthy interaction with others. He made a call to a 900 number as a way to engage in conversation with a woman.
6. In individuals under age 18 years, the duration is at least 6 months.
   • Even though Barry is in his forties, he has evidence of symptoms beyond 6 months. According to his sisters stories of Barry as a child, he might have been diagnosable before 18 years of age.
7. The fear or avoidance is not due to the direct psychological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition and is not better accounted for by another mental disorder (e.g., panic disorder with or without agoraphobia, separation anxiety disorder, body dysmorphic disorder, a pervasive developmental disorder, or schizoid personality disorder).
8. If a general medical condition or another mental disorder is present, the fear in Criterion A is unrelated to it, e.g., the fear is not of stuttering, trembling in Parkinson’s disease, or exhibiting abnormal eating behavior in anorexia nervosa or bulimia nervosa.
   • Barry appears not to be on any medications or illegal drugs, nor does he appear to have another diagnosable mental disorder.

Specify if:

• Generalized: if the fears include most social situations (also consider the additional diagnosis of Avoidant Personality Disorder)
  • It appears that Barry works well with the other men in his company although Barry’s interaction with the men is limited and somewhat awkward.

Accuracy of Portrayal

There are few portrayals of a main character with social phobia in movies and television. Barry’s character in the movie gave an excellent portrayal of someone suffering from social phobia and the struggles they must face on a daily basis. The portrayal of his seven sisters gave a good indication that his upbringing was a humiliating and traumatic experience and gave insight into reasons why Barry might suffer from the disorder. Barry’s relationship with Lena is less accurate to the “real-life” relationship someone with social phobia might experience. His awkward demeanor, inability to maintain eye contact, and lack of conversation skills were accurately portrayed. The manner in which the two met was also likely since Lena pursued Barry and made most of the first moves in the relationship. The inaccuracy is in the fact that Barry and Lena found love and appeared to “live happily ever after,” which unfortunately does not happen for many individuals diagnosed with social phobia. In addition, Barry’s love for Lena seemed to give him the courage to confront the criminals that were taking advantage of him; however, it is unlikely for someone with social phobia to be assertive or confrontational. These two factors do not exclude social phobia as a diagnosis for Barry, they are just not the norm for what one might expect for someone diagnosed with social phobia.

Treatment

Cognitive behavioral therapy is likely the most effective treatment for Barry. This treatment will help change Barry’s pattern of thought about certain events by helping Barry better understand the reality of the situation and help Barry focus less on the idea that he will be embarrassed or humiliated. He will learn to identify and change his automatic negative thoughts. He will learn that everybody makes mistakes and that sometimes being embarrassed is going to happen but it will be okay. Therapy will also help give him coping strategies to change his behavior in anxiety provoking situations, as well as, giving him the skills to help manage his emotions and violent temper. Exposure therapy will help Barry learn that he can handle social situations without anxiety. Family therapy would likely not benefit Barry greatly but may help enlighten his sisters on the cause and effect their actions have on others lives. It would likely be most beneficial to meet with each sister one at a time with Barry as opposed to as a whole group.

Name: Charlie Kaufman

Source: Adaptation (movie, 2002)

Background Information

Charlie Kaufman is a Caucasian male in his mid-forties who lives with his twin brother Donald in an apartment they share together. He is a screenwriter who has been tasked with producing an adaptation of the book The Orchid Thief by Susan Orlean. Charlie appears to be suffering from some form of depression because he is constantly in doubt of his abilities to adapt the novel into a formidable screenplay, which affects his daily routines and interactions with his brother. There is no evidence of substance abuse (either drugs or alcohol), and he does not appear to be predisposed to partaking in consumption of dangerous substances. Charlie’s brother Donald constantly agitates him because he is embarking on a career in screenwriting and Charlie does not approve of his methods; he is baffled when Donald sells his work for a large amount of money. Charlie appears to have trouble with starting and maintaining close personal relationships, as evidenced by his awkwardness with a former girlfriend and a waitress at a local diner he frequents. He is able to start conversations but does not know how to keep them going and is not particularly skilled at inviting other people to join him in activities.

Description of the Problem

Charlie is a socially awkward person and although he is able to start minimal conversations with strangers and acquaintances, he is very nervous and cannot seem to keep his thoughts in one particular order that would benefit the situation. His family support system seems to only come from his twin brother, who is almost completely opposite in terms of personality, social interactivity, and general comfort with life. Since a lot of his thoughts are narrated for the audience, it is apparent that he craves relationships and people to share life experiences with but cannot bring up the courage to engage anyone past initial conversations. Charlie suffers from a severe case of writer’s block and takes his anger out on his brother, who is subsequently flourishing in his screenwriting endeavors. Much to the chagrin of Charlie, Donald seems to have picked up screenwriting and ran away with it and that bothers Charlie because he deems Donald an inferior screenwriter and too cliché to produce anything worthwhile. Charlie’s anxiety in social situations is profound and is outlined by a fantasy he indulges in regarding the diner waitress.

Diagnosis

The diagnosis for Charlie Kaufman is Social Phobia (300.23). According to the DSM-IV-TR the following criteria are met:

1. A marked and persistent fear of one or more social or performance situations in which the person is exposed to unfamiliar people or to possible scrutiny by others. The individual fears that he or she will act in a way (or show anxiety symptoms) that will be humiliating or embarrassing. NOTE: In children, there must be evidence of the capacity for age-appropriate social relationships with familiar people and the anxiety must occur in peer settings, not just in interactions with adults.
   • Charlie shows a marked level of anxiety and fear when introduced to new people, especially in social situations. Excellent examples of these situations are when he meets a former girlfriend’s new “friend,” and when he is served by the waitress at the diner.
2. Exposure to the feared social situation almost invariably provokes anxiety, which may take the form of a situationally bound situationally predisposed panic attack. NOTE: In children, the anxiety may be expressed by crying, tantrums, freezing, or shrinking from social situations with unfamiliar people.
   • When Charlie meets the ex-girlfriend’s “friend”, it is obvious that he is speechless and cannot speak to him or the ex-girlfriend about his current situation. The waitress at the diner also causes Charlie to suffer through anxiety that freezes his conversation and makes the interaction very awkward.
3. The person recognizes that the fear is excessive or unreasonable.
   • Charlie knows that he is a socially awkward person and his continued interactions with his twin brother as well as his trip to New York to talk to Susan Orlean highlight his need to express himself in a socially acceptable way.
4. The feared social or performance situations are avoided or else endured with intense anxiety or distress.
   • On the trip to New York, Charlie ultimately avoids speaking with Susan Orlean and instead attends Robert McKee’s seminars. He then has Donald imitate him and interview Susan so he does not have to face her.
5. The avoidance, anxious anticipation, or distress in the feared social or performance situation(s) interferes significantly with the person’s normal routine, occupational (academic) functioning, or social activities or relationships, or there is marked distress about having the phobia.
   • Charlie’s avoidance behaviors and awkward social interactions severely hinder him from completing the screenplay and even render his trip to New York a waste of time and ultimate threat to his life as he is not able to talk to Susan Orlean in person.
6. In individuals under age 18 years, the duration is at least 6 months.
   • Charlie is well above the age of 18, but the film seems to suggest that his problems have persisted well beyond 6 months.
7. The fear or avoidance is not due to the direct psychological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition and is not better accounted for by another mental disorder (e.g., panic disorder with or without agoraphobia, separation anxiety disorder, body dysmorphic disorder, a pervasive developmental disorder, or schizoid personality disorder.)
   • Charlie’s social awkwardness and anxiety due to the social situations is not accounted for with any other condition or disorder. He seems to be genuinely suffering from a social phobia and no drugs or alcohol influence his behaviors.
8. If a general medical condition or another mental disorder is present, the fear in Criterion A is unrelated to it, e.g., the fear is not of stuttering, trembling in Parkinson’s disease, or exhibiting abnormal eating behavior in anorexia nervosa or bulimia nervosa.
   • Charlie is not under the influence of any substances (legal or illegal), and his condition seems to be independent of any other diagnoses.

Specify if:

• Generalized: if the fears include most social situations (also consider the additional diagnosis of Avoidant Personality Disorder.)
  • Charlie is able to maintain a steady job, do excellent work, and keep relationships with coworkers and everyday acquaintances, though to a minimal extent and not without awkward social interaction.

Accuracy of Portrayal

Charlie Kaufman is an adequate representation of a person suffering from a social phobia. It is not a perfect rendition, but it covers the base areas well enough to establish a passing resemblance. The character is not completely socially awkward, as he is able to strike up a conversation a few times (which do not lead to any sort of reliable, close relationship.) Charlie’s brother Donald plays a nice juxtaposition to his social anxiety and awkwardness, as evidenced by Donald’s general openness and lack of social anxiety. This suggests that, as children, Charlie probably suffered greatly from witnessing his brother’s easiness with social situations. A huge inaccuracy is the fact that Charlie becomes assertive and decides to fly to New York on a whim to meet with Susan Orlean. Also, his sudden insistence to check out what is going on between Susan and John Laroche is not typical of someone suffering from social phobia in any context. Although nothing good comes of these actions, the sheer fact that he pushed his social anxieties aside for those particular instances does not accurately portray someone with full blown social phobia. These are the only flaws portrayed by Charlie and the depiction is a passable example of social phobia.

Treatment

The most effective route to take with a person suffering from social phobia would be a treatment centered on cognitive behavioral therapy. This type of therapy could alter Charlie’s thought processes to allow him to acclimate himself to social situations in a socially acceptable manner. Through cognitive behavioral therapy, Charlie could slowly eliminate negative thoughts attached to social situations and therefore be comfortable enough to pursue relationships outside of the scope he has become accustomed to developing his entire life. He would be able to cope with social stressors such as the inevitable times when meeting new people will not go over very well and the situations in which established relationships start to deteriorate for numerous reasons. Slowly integrating real-life situations into the therapy (exposure) would then help Charlie come to terms with the changes that would come in his life and set him on the path to being a socially normal person. If the therapy was effective, Charlie would not become a new man overnight; rather, it would probably take years and consistent dedication to the changes to see him become adaptive to social situations.