559717

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CCSXXX10.1177/1534650114559717Clinical Case StudiesWilliams et al.

Article
Clinical Case Studies
2015, Vol. 14(5) 323­–341
Cognitive-Behavioral Treatment © The Author(s) 2014
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DOI: 10.1177/1534650114559717
Comorbid Paranoid Schizophrenia ccs.sagepub.com

Monnica T. Williams1,2, Michelle C. Capozzoli1,3,

Erica V. Buckner2, and David Yusko1

Abstract
We report on the cognitive-behavioral treatment (CBT) of a patient with comorbid social
anxiety disorder (SAD), schizophrenia, and major depressive disorder, complicated by alcohol
abuse. Symptoms included auditory hallucinations that commented on the patient’s behavior
and paranoid thoughts. The paranoid symptoms affected his social interactions as this included
the fear that his thoughts may be heard and judged by others. Therapeutic activities raised
awareness as to how avoidance interferes with and perpetuates the cycle of depression and
psychosis while maintaining symptoms of SAD. Psychoeducation was provided about factors
that maintain social anxiety and increase social isolation. New skills were obtained by helping
the patient discover alternative ways to view social situations, experimentation, and real-world
application to disprove notions about others’ predicted behavior. Treatment led to a great
reduction in social anxiety, depression, and suspicious thinking. This case study demonstrates
that SAD symptoms in a patient experiencing psychosis can be effectively treated using CBT.

Keywords
social anxiety disorder, social phobia, comorbidity, schizophrenia, therapy

1 Theoretical and Research Basis for Treatment

The relationship between schizophrenia and anxiety disorders, particularly social anxiety disor-
der (SAD), has been examined more closely in the literature in recent decades. Meta-analytical
results indicate that about 14.9% of those with schizophrenia have SAD (Achim et al., 2009),
and this comorbidity is associated with lower subjective quality of life, lower levels of employ-
ment, and higher levels of paranoia (Kumazaki et al., 2012; Lysaker et al., 2010). Despite their
frequent co-occurrence, few studies have examined the efficacy of treating SAD among indi-
viduals with schizophrenia. Cognitive-behavioral treatment (CBT) for SAD has demonstrated
effectiveness (Hofmann & Smits, 2008), and central treatment components include developing

1University of Pennsylvania, Philadelphia, USA

2University of Louisville, KY, USA
3University of Nebraska–Lincoln, USA

Corresponding Author:
Monnica T. Williams, Department of Psychological and Brain Sciences, Center for Mental Health Disparities,
University of Louisville, KY 40292, USA.
Email: [email protected]
324 Clinical Case Studies 14(5)

a cognitive-behavioral conceptualization of SAD with the patient, cognitive restructuring, and

exposure to social situations. However, it is typical for individuals with psychosis to be excluded
from clinical trials testing CBT for SAD. As a result, the treatment has been largely tested
among non-psychotic participants, and it has not been clearly established that the treatment is
effective among those with psychosis.
Although no individually delivered treatments for SAD have been systematically tested
among individuals with schizophrenia spectrum disorders, at least two small trials have exam-
ined group treatments. Halperin, Nathan, Drummond, and Castle (2000) randomly assigned 20
individuals with schizophrenia and comorbid SAD to 6 weeks of group CBT for SAD or wait-list
control. The group treatment involved exposure, cognitive restructuring, and homework assign-
ments between sessions. Results demonstrated significant improvement in symptoms of social
anxiety, depression, and quality of life. Using a similar treatment model, Kingsep, Nathan, and
Castle (2003) randomly assigned 33 individuals with schizophrenia and comorbid SAD to 12
weeks of group CBT for SAD. In addition to replicating the results of the previous study, improve-
ments were maintained at 2-month follow-up. It should be noted that in both studies, treatment
was adapted to be appropriate to the population by using methods to increase engagement and
rapport, increase task specificity, and progress at a slower pace. In addition, based on the study
outcome measures, participants remained highly symptomatic post-treatment.
Although the two previously described studies provide an overview of the components and
structure of SAD treatment for those with schizophrenia, the nature of the published reports pre-
vents examination of the challenging clinical issues present in this population. Individuals with
schizophrenia demonstrate unique impairments (e.g., in social cognition) that are uncommon in
the non-psychotic population for which the treatment was originally designed and validated. In
addition, it is hard to generalize group treatment findings to individual treatment as people with
the most severe SAD are generally unwilling to consider group treatment due to the nature of
their fears. Thus, participants in group therapy may be higher functioning in general. Unfortunately,
case studies that have addressed this topic in more depth have been limited to brief reports that
have not described in detail the course of treatment (e.g., Tully & Edwards, 2009). Because of the
unique issues that present among this population when conducting CBT for SAD, it is expected
that the following detailed description of the successful individual treatment of SAD symptoms
in a patient presenting with comorbid SAD and schizophrenia may benefit clinicians attempting
to provide similar treatment.

2 Case Introduction
Brian (pseudonym) was a 22-year-old non-Hispanic White man who was referred to the
University of Pennsylvania’s Center for the Treatment and Study of Anxiety (CTSA) by his psy-
chiatrist. He was taking several medications for symptoms of psychosis and depression:
Trazodone (100 mg), Effexor (300 mg), Topamax (100 mg), Lamictal (200 mg), Risperdal (4
mg), and an unidentified benzodiazepine.
Brian reported that these symptoms had been significantly reduced and had become manage-
able. However, he described severe social anxiety that was distressing and interfered with his daily
functioning. Brian reported that previously, it was his psychosis that prevented him from complet-
ing college or maintaining full-time employment. However, now that these symptoms were well-
managed, he attributed his inability to resume college or establish employment to social anxiety.
He also reported depression and difficulty concentrating that interfered with his functioning.

3 Presenting Complaints
At the initial evaluation, Brian reported difficulty in a number of social situations, including
interacting in small and large groups of people, introducing himself to others (especially women),
Williams et al. 325

having conversations with unfamiliar people, taking public transportation, and going to restau-
rants and movie theaters. He feared that he would do something stupid and that others would find
him weird and would tease him. In addition, Brian feared that others would hear his thoughts,
which he described as “crazy.” Because he had been avoiding social interactions, he believed that
his social skills were weak and that he lacked appropriate social boundaries, which he feared
would lead him to say something inappropriate.
Brian reported that when he did engage in social situations, he experienced a high level of
anticipatory anxiety and worried about how he would appear to others. Specifically, he was con-
cerned that people would stare at him, that he would babble or speak incoherently, and that others
would subsequently consider him incompetent and reject him. Brian reported focusing almost
entirely inwardly during social situations and frequently ruminated about his performance after
engaging in feared social situations.
In addition to SAD, Brian reported frequent auditory hallucinations (i.e., voices that commented
on his behavior) and paranoid thoughts but was generally able to recognize these as psychotic
symptoms. He denied visual hallucinations and did not demonstrate disorganized speech, grossly
disorganized or catatonic behavior, or prominent negative symptoms. Brian also met criteria for
major depressive disorder (MDD). His main depressive symptoms included feeling fidgety and
restless, decreased energy, and difficulty concentrating. He reported having symptoms for the vast
majority of the past 5 years. These symptoms resulted in considerable disability as Brian was not
able to work or attend school. The main barrier to enrolling school was his fears about what others
would think of him. He worried that students would judge him and be able to hear his thoughts and
that the professors would think he was unintelligent. The possibility of being called upon or being
required to give an oral presentation in class were also major sources of anxiety.

4 History
Brian was raised in an upper-middle-class family in a metropolitan area in Delaware with an
older sibling. Brian reported that he had experienced symptoms of SAD since early childhood. At
age 17, he started having auditory hallucinations. He attempted to commit suicide by overdosing
on drugs at age 18 and was subsequently hospitalized and diagnosed with MDD with psychotic
features. At age 20, Brian was diagnosed with schizoaffective disorder by a different mental
health provider. He continued to be hospitalized for suicide attempts and suicidal ideation 5 times
after his initial hospitalization, and he completed a 12-step treatment program for alcohol abuse.
Brian had been diagnosed with schizoaffective disorder and attention deficit hyperactivity disor-
der (ADHD) by his prescribing physician.

5 Assessment
Brian’s symptoms of social anxiety, depression, and psychosis were assessed with clinician-
administered and self-report measures, which included the following:

Mini International Neuropsychiatric Interview (MINI)

The MINI (Sheehan et al., 1998) is a structured clinical interview used to assess the most com-
mon psychiatric disorders and has excellent psychometric properties, including strong conver-
gent validity with other structured clinical interviews.

Liebowitz Social Anxiety Scale (LSAS)

The LSAS (Liebowitz, 1987) is a 24-item clinician-administered measure, in which clinicians
ask respondents to rate both fear and avoidance on a 0 (none) to 4 (extreme) scales. Regularly
326 Clinical Case Studies 14(5)

used in treatment outcome research for SAD, the LSAS has demonstrated good psychometric
properties (Baker, Heinrichs, Kim, & Hofmann, 2002). Mennin et al. (2002) suggested cutoff
scores of >30 for social phobia, and >60 for generalized social phobia.

Beck Depression Inventory (BDI)

The BDI (Beck, Steer, & Garbin, 1988) is a 21-item self-report scale that assesses the severity of
affective, cognitive, and physiological components of depression. Total scores of 10 or less are
considered normal, while scores of 20 or greater suggest clinical depression. The BDI has excel-
lent reliability and validity and is utilized frequently in treatment outcome research.

Social Phobia Inventory (SPIN)

The SPIN (Connor et al., 2000) is a 17-item self-report scale that assesses fear, avoidance, and
physiological arousal associated with SAD. Items address a range of social interactions, fears of
embarrassment, and discomfort with physical symptoms of social anxiety. Higher scores indicate
a greater level of symptom severity, and a cutoff score of 19 has been demonstrated to distinguish
between individuals with SAD and non-anxious controls 79% of the time (Connor et al., 2000).
The SPIN has been tested in clinical and non-clinical samples and has been found to have sound
psychometric properties (Connor et al., 2000).

Social Phobia Weekly Summary Scale (SPWSS)

The SPWSS (Clark et al., 2003) is a six-item self-report scale that measures social anxiety symp-
tom severity, including self-focus in feared social situations. Items responses range from 0
(entirely externally focused) to 8 (entirely self-focused), and total scores are calculated by obtain-
ing a mean of all items. Internal consistency of the SPWSS is good (α = .81). Although no data
have been published regarding suggested cutoff scores for the SPWSS, a clinical trial indicated
that individuals effectively treated for SAD with individual cognitive therapy had a baseline
mean score of 5.4 (SD = 1.7) and a post-treatment mean score of 2.7 (SD = 2.3; Mörtberg, Clark,
Sundin, & Åberg Wistedt, 2007).

Inventory of Hostility and Suspiciousness (IHS)

The IHS (Huppert, Smith, & Apfeldorf, 2002) is a 19-item measure of psychotic thinking/para-
noia. Item ratings are converted into a Likert-type scale ranging from 0 (not at all characteristic
of me) to 4 (extremely characteristic of me). Items are summed for a total score, with higher
numbers indicating greater psychopathology. The overall internal consistency of the measure is
excellent (α = .98 for anxious outpatients; α = .85 for schizophrenia patients; Huppert et al.,
2002). IHS means are 25.72 (SD = 21.39) for outpatients and 21.13 (SD = 11.33) for students (E.
Buckner, Keen, Tellawi, & Williams, 2013).

Quality of Life Enjoyment and Satisfaction Questionnaire (Q-LES-Q)

This is a 16-item, self-rated measure of physical health, subjective feelings, leisure activities,
social relationships, general activities, satisfaction with medications, and life satisfaction domains
(Endicott, Nee, Harrison, & Blumenthal, 1993). Each item is scored on a 5-point Likert-type
scale (1 = very poor to 5 = very good). The Q-LES-Q has demonstrated strong internal consis-
tency and construct validity for individuals with SAD and severe mental illness (Ritsner, Kurs,
Gibel, Ratner, & Endicott, 2005; Sung et al., 2012). A pre-to post-treatment decrease of at least
Williams et al. 327

6.8% has been suggested as a minimum responder threshold (Harnam, Wyrwich, Revicki,
Locklear, & Endicott, 2011).

Subjective Units of Distress Scale (SUDS)

The SUDS (Wolpe, 1969) is an important procedural element in behavior therapy to assess the
subjective experience of anxiety, and the SUDS since been incorporated into many treatment
protocols for anxiety disorders. It is a simple method that enables clinicians to anchor patients’
self-rated distress in various anxiety-provoking situations at baseline, monitor changes, and to
evaluate the progress of therapy. Situations can be ranked from least to greatest amount of anxi-
ety as measured by the patient’s reported SUDS, 0 (no anxiety, calm) to 100 (very severe anxiety,
worst ever experienced).
Brian was first administered the MINI, which indicated a diagnosis of schizophrenia, rather
than schizoaffective disorder, as originally reported by the patient. Brian’s total LSAS score
was 129 at pre-treatment, which is indicative of severe social anxiety symptoms. He also
exhibited intense paranoia of others hearing his thoughts and passing judgment on him; hence,
he often avoided situations that elicited these feelings. He reported that he would rather stay at
home than experience the rush of intense fear. Consequently, Brian developed safety behaviors
to mitigate the intensity of the anxiety and avoided or escaped early from various social activi-
ties (e.g., restaurants, movie theaters, concerts, classes). In addition to anxiety-related symp-
toms, SAD is an interpersonal disorder that disrupts relationships with others (Alden & Taylor,
2004). As such, Brian’s fear of social situations in concert with isolation impaired his ability to
develop and maintain relationships and peruse career goals. Brian’s avoidance and safety
behaviors perpetuated his maladaptive coping behaviors, leading to social isolation, alcohol
abuse, and depressed mood.
Brian’s BDI score was 17 at pre-treatment, which represents mild depressive symptoms. His
depression could be attributed to social isolation and behavioral inactivity, exacerbated by alco-
hol abuse. Brian’s depression may also have been related to his self-reported inconsistent use of
his medications combined with alcohol, which was contraindicated. In general, all of these poten-
tial contributing factors warranted clinical attention and management to ensure a favorable
outcome.

6 Case Conceptualization
Brian’s symptoms were conceptualized using a cognitive-behavioral model (Clark & Wells,
1995). Early experiences were presumed to create assumptions in Brian about himself and the
world that led him to have excessively high standards for his social performance, conditional
beliefs concerning performing in a certain way, and unconditional negative beliefs about himself.
Brian’s fear that he may do something to embarrass himself in social situations was interpreted
as a common symptom of SAD. However, one of the sources of this was his concern that others
may hear his thoughts and judge him, and therefore a synergistic relationship existed between
SAD and his delusions. These beliefs led him to appraise social situations as dangerous and inter-
pret ambiguous or neutral information as signs of negative evaluation.
Following Clark and Wells’s (1995) model of SAD, Brian’s fear of social situations was con-
ceptualized as maintained through several processes, including viewing himself as a social object
in which his attention is allocated to detailed self-monitoring. Furthermore, relative to socially
anxious thoughts of non-psychotic individuals, it is expected that Brian’s fear that others could
hear his thoughts may have been more intrusive and difficult for him to challenge. In addition, to
minimize occurrence of a feared catastrophe, Brian performed a number of “safety behaviors”
(e.g., placing his sweatshirt hood over his head), which in turn increased self-focused attention,
328 Clinical Case Studies 14(5)

producing cognitive and somatic symptoms of social anxiety and drawing others’ attention.
Brian’s avoidance of feared social situations was viewed as an escape from the anxiety that
accompanies approaching those situations. Brian’s subsequent use of safety behaviors in these
situations prevented learning that his feared outcome of embarrassing himself may not actually
come true, and in fact these feared outcomes typically do not occur.
Brian’s depression included anhedonia, difficulty concentrating, low motivation, and lethargy.
SAD and MDD are commonly comorbid, with estimates of comorbid MDD in individuals with
SAD ranging up to 74.5% (Koyuncu et al., 2014). Because behavioral avoidance has been found
to mediate the relationship between social anxiety and depression (Moitra, Herbert, & Forman,
2008), Brian’s symptoms of depression were conceptualized as occurring due in part to his with-
drawal from social situations and other rewarding activities involving social interaction.
Behavioral activation was expected to alleviate symptoms of depression by using activation strat-
egies (e.g., activity scheduling) to counter patterns of inactivity, withdrawal, and avoidance and
increase positive reinforcement (Lejuez, Hopko, Acierno, Daughters, & Pagoto, 2011). Although
Brian’s symptoms of depression were largely conceptualized by social avoidance, some of his
symptoms (e.g., low motivation, lethargy) may have been related to factors outside of SAD.
Specifically, depressive symptoms may have been directly related to the patient’s schizophrenia
and may have in fact been in response to his schizophrenia. Furthermore, his depressive symp-
toms may have been related to his antipsychotic medication, which is often associated with seda-
tive and other side effects (Leucht et al., 2013).

7 Course of Treatment and Assessment of Progress

Treatment sessions were generally once weekly for 22 weeks, for 50 to 90 min. At each session,
the severity of Brian’s social anxiety and depression was measured by questionnaires, including
the SPWSS, SPIN, and BDI. The treatment protocol was based on CBT principles for the treat-
ment of SAD and depression (Huppert, Roth, & Foa, 2003).

Treatment Session 1
During the first session, Brian’s therapist (M.T.W.) gathered information about the nature of his
social anxiety and asked him to list social situations in which he would like to be able to engage
in and feel more comfortable. Brian described a number of problematic situations, listed in
Table 1 with accompanying SUDS ratings. For example, he wanted to attend concerts and par-
ties, but it was difficult due to crowds, noise, and lack of personal space. He worried that others
would hear his thoughts and think that he was “weird” and “crazy.” He also believed that he pos-
sessed poor social skills and that he would act inappropriately in social situations. Brian also
listed introducing himself to strangers (especially women), going to movies, making phone calls,
holding a job, and using public transportations as feared situations that he often avoided but
wished to begin engaging in.
The therapist informed him that the goal of treatment was to help him to engage in those situ-
ations, and Brian agreed that this was a reasonable goal. The therapist provided a cognitive-
behavioral conceptualization of SAD and how CBT can help treat symptoms of social anxiety.
Brian was assigned homework to review the model of social anxiety.
Because of his history of attempted suicide and current MDD, suicidality was assessed
throughout the treatment process by periodically asking him directly about suicidal thoughts. In
addition, he was administered a weekly measure of depression (BDI), which included a direct
question about suicidality (BDI item #9). This question was examined at each visit, along with
his responses to the other related questions to help ensure safety.
Williams et al. 329

Table 1.  Pre-Treatment Hierarchy of Feared Social Situations.

Item SUDS score

Going to a concert 95
Taking public transportation 95
Giving presentation or speech to a small group 90
Going to a house party with some unknown people 80
Sitting in a classroom (being called on and not having homework) 80
Returning an item to a store 70
Going to a theater for a movie or play 65
Conversation with a person in line at convenience store 65
Conversation with small group of new people 60
Extended conversation with stranger 55
Sitting alone in a restaurant or cafeteria 55
Going to a restaurant with family 45
Job interview 45
Introducing self to women 40

Note. SUDS = Subjective Units of Distress Scale (0-100).

Treatment Session 2
Brian rescheduled his next session due to anxiety about not completing his homework and feel-
ing depressed. He eventually completed his homework and attended the rescheduled session. The
therapist reviewed with Brian his safety behaviors in social situations as avoiding eye contact,
placing his hood over his head to avoid drawing attention to himself. He also reported wiping his
mouth several times after eating to avoid embarrassing himself by having food on his face. He
also focused on seeming stupid, noticeably “freaking out,” saying embarrassing things, and oth-
ers could hear his thoughts. To demonstrate the detrimental effects of safety behaviors or at least
that they are unnecessary, Brian engaged in two conversations with confederates. He was
instructed to use his safety behaviors as usual in the first conversation but not to use these behav-
iors in the second conversation. In the second conversation, he was encouraged to focus his atten-
tion outward toward the conversation itself, instead of focusing inward on how the other person
may be hearing his thoughts and evaluating his performance.
In the first confederate conversation, with safety behaviors engaged (e.g., avoiding eye con-
tact) and self-focused attention, Brian predicted a higher rating of distress prior to the conversa-
tion than his reported peak rating. Unfortunately, he reported that when he used safety behaviors,
his actual ratings of these concerns were much lower than his initial predicted scores. For exam-
ple, he reported lower levels of distress in regard to “seeming stupid,” “saying embarrassing
things,” and “hearing my thoughts/feelings,” when he engaged safety behaviors.
However, the second confederate conversation (outward focus; disengaged safety behaviors)
revealed that Brian’s peak distress level was higher than the peak distress rating for the initial
confederate conversation. Prior to the second confederate conversation, Brian predicted his dis-
tress rating of 2 for “seeming stupid”; however, his actual peak distress rating was 8 (on a scale of
1-10, where higher numbers were more extreme). Therefore, when he repeated the conversation
with the confederate and dropped safety behaviors, he felt more stupid after the exposure, less of
a sense of freaking out (6 vs. 4), no change in his experience of having said something embarrass-
ing (7 vs. 7), and a large drop in his sense of others being able to hear his thoughts (6 vs. 1). From
the video feedback, the patient rated that he looked anxious (7) but rated himself a 0 on all other
items (seeming stupid, freaking out, saying something embarrassing, or hearing his thoughts).
330 Clinical Case Studies 14(5)

With this information, it can be deduced that Brian experienced the bulk of his distress when
he engaged in self-focused attention. Although it appeared that the safety behaviors buffered his
distress, as evident of the lower (peak) distress rating, the safety behaviors encouraged with-
drawal in social interactions. Consequently, avoidance and the practice of safety behaviors pre-
vented coping in a healthy and adaptable manner. As such, continued maladaptive coping (i.e.,
self-focused attention and avoidance behaviors) exacerbated his social challenges.
Following the exposure, Brian and the therapist reviewed a video recording of the session to
see how these two conversations differed. The patient reported that he did not perform as badly
in the conversations as he expected, particularly the one in which he was not using his safety
behaviors. In addition, the confederate completed ratings of Brian’s social anxiety, performance
during the conversation, and whether his thoughts were heard.
At the end of each session, homework was assigned for the upcoming week, which included
engaging in specific social situations typically avoided, recording anxiety, and doing scheduled
activities to alleviate depression. Telephone contacts were scheduled as needed in between ses-
sions to monitor progress with homework assignments. After Session 2, Brian’s homework was
to self-monitor anxiety during outward focus exercises and draft a preliminary hierarchy of activ-
ities to practice.

Treatment Sessions 3 and 4

Brian did not complete his homework due to traveling during the Thanksgiving holiday. However,
he reported that he accompanied his family in visiting extended family, which he said he would
have avoided prior to treatment due to social anxiety. Furthermore, Brian reported that the visit
was not as anxiety-provoking as he had expected. In session, the therapist planned for him to
participate in a conversation with a confederate, with a pre-selected topic about movies. Brian
completed a pre-exposure rating form, estimating how severe the feared consequences would be
(embarrassment, appearing stupid, and the confederate hearing his thoughts). The confederate
was also given a rating form to rate Brian’s observable behaviors after the completion of the
interview. Prior to the exposure, Brian reported feeling depressed and therefore did not feel
anticipatory anxiety about the conversation, but exposures were conducted despite his mood. It
was perceived that if the patient could “escape” exposures due to unpleasant feelings, there
would be counterproductive rewards for a negative mood. Following the exposure, Brian rated
on a 0-10 scale (0 = poor performance/no anxiety; 10 = peak performance/maximum anxiety) his
overall performance as a 7, and his anxiety as a 2. He also reported no feelings of stupidity or
embarrassment, and he did not think the confederate could hear his thoughts. The confederate
ratings of the patient were similar: 8 for performance and no reports of observable stupidity and
embarrassment, and he could not hear the patient’s thoughts. These ratings were shared with
Brian to help disconfirm his inaccurate beliefs.
In Session 4, Brian reported completing his homework which consisted of the following: tak-
ing two walks where he practiced outward focusing, attending a funeral, going to the store, and
attending an online chat game. During these social activities, he reported being very anxious with
his SUDS at 70. However, he reported while walking the dog, he was able to focus outwardly
without feelings of anxiousness. The patient also reported safety behaviors of frequent mouth
wiping after eating, avoiding eye contact, and wearing a hat or hood.
Last, the patient participated in an in-session exposure of introducing himself to a female
research assistant. The patient’s pre-SUDS was 35 and post-SUDS was 45. Prior to the exposure,
Brian reported fearing that his face would appear flushed and that his conversation partner would
detect his nervousness. Following the exposure, he reported that his face had flushed and that he
had begun to sweat during the conversation. In processing the exposure, the therapist focused on
whether the conversation partner had taken note of physiological changes reported by the patient.
Williams et al. 331

Upon reflection, Brian said he believed that she probably had detected his flushed face but may
not have noticed his sweating. The therapist-assigned homework was for the patient to introduce
himself to a female every day and record his anxiety, in addition to continuing behavioral activa-
tion daily for depression.

Treatment Sessions 5 to 8
In Session 5, Brian reported that he did not go out much due to his grandparents being in town.
However, he did introduce himself to five women at a party (SUDS = 45). The patient reported
that introducing himself to women became much easier with practice. Brian also reported going
out to eat with family and friends, going to the mall, and walking the dog. He reported an overall
good mood and feeling less anxious as he had increased his practice of focusing externally. The
exposure hierarchy was revisited, and the patient reported decreased SUDS in the following situ-
ations: introducing self to a woman, 25 (initially 40); attending a job interview, 30 (initially 45);
going to a restaurant with family, 10 (initially 45); and returning an item to the store 20 (initially
70). Subsequently, an in-session exposure activity was arranged at the cafeteria. Brian was asked
to sit in the cafeteria alone for 25 minutes until his anxiety decreased; the patient started with a
SUDS of 50, with a peak of 65 during the exposure, and post-SUDS of 0. For homework, the
patient was instructed to practice sitting alone at restaurants or coffee shops 3 to 4 times and to
initiate conversation at a store 3 to 4 times.
Although at Session 6 Brian did not complete all of his homework, he did report going to fast
food restaurants, spending time with his friends twice, and going to a store. Although the patient’s
anxiety and depression had decreased, he still reported that most of his anxiety was attributable
to concern about others hearing his thoughts. Brain identified greatest concern about embarrass-
ing things, private thoughts (e.g., minor lies told to friends so as not to hurt their feelings), morbid
thoughts (e.g., fear that family members may contract serious medical illnesses), and “stupid”
thoughts (e.g., ingredients to add to water to make it taste better). As a result of this concern, he
reported trying to control his thoughts, which was identified as a safety behavior. The therapist
also discussed the importance of completing homework and reviewed the obstacles that were
inhibiting homework completion. One obstacle Brian identified was not having access to a car to
drive to various locations to complete assigned exposure exercises. Although he was able to
drive, he reported he had totaled his car in an accident and that his parents did not allow him to
drive their cars. With Brian’s permission, his father was invited into the session to discuss logis-
tics associated with completing homework. The purpose of the exercises was explained, and his
father agreed to allow Brian to use the family cars for this purpose. His father also asked the
therapist about Brian’s progress, and the therapist reported that Brian had made substantial prog-
ress, particularly in decreasing his avoidance of feared social situations.
At Session 7, Brian reported that he completed most of his assigned homework, including
watching a movie in the theater twice, going to a restaurant twice, and leaving his house daily to
walk the dog or visit with friends. He reported that attending one movie was less anxiety-provok-
ing than the other, which he attributed to being more engaged in that particular movie. At the
other movie, Brian reported being less engaged in the movie and more preoccupied with feeling
trapped as it was not socially acceptable to step out of the movie, and that others could hear his
thoughts and would think negatively of him. Based on Brian’s report, it appeared that he was
starting to see the beneficial effects of focusing his attention outward and how focusing inward
tended to increase his level of anxiety. He reported not feeling well during session due to exces-
sive drinking the night before.
The therapist did not tell Brian that his delusions were false but continued to challenge him to
engage in experiments to determine the truth on his own. To that end, Brian participated in an
exposure experiment by telling a lie to a confederate about his current place of employment; he
332 Clinical Case Studies 14(5)

predicted at a 5 of 10 that the confederate would identify the lie by reading his thoughts and
would smirk or grin at him as an indication of this. The patient subsequently performed his safety
behavior by putting his hood on his head. Following the exposure, he rated a likelihood of 6 of
10 that the confederate sensed he was lying and 4 of 10 that the confederate heard his thoughts.
Overall, Brian felt that the conversation went well. He also reported, however, that he found it
easier to focus outward when he was hungover. The patient also participated in another experi-
ment with a confederate to test whether another person could hear his thoughts of cursing in his
head. Brian reported his pre-, peak-, and post-SUDS as 85, 90, and 70, respectively. The confed-
erate reported that he could not hear patient’s thoughts, but Brian continued to doubt that his
thoughts were private. Homework was assigned and included sitting in a restaurant while inten-
tionally having negative thoughts, refrain from trying to control his thoughts around others, and
to attend a movie 2 to 3 times.
At Session 8, Brian reported that he did not complete his homework, as he was “feeling lazy.”
An in-session exposure was conducted with the patient sitting alone in the cafeteria, intentionally
having bad thoughts and trying to project these onto others. He predicted that others would react
to these thoughts by judging and laughing at him. His pre-, peak-, and post-SUDS were 40, 60,
and 15, respectively. Following the exposure, Brian noted that no cafeteria patrons exhibited any
signs of being able to detect his thoughts. Thus, the exposure served to provide corrective infor-
mation for Brian, as he learned that people may not be able to hear his thoughts, or if they did,
they did not seem to care.

Treatment Sessions 9 and 10

As Brian became more comfortable in social situations, the proceeding sessions included expo-
sures involving higher anxiety-provoking interactions. In Session 9, Brian completed most of his
homework, through which he disconfirmed some of his maladaptive beliefs. Specifically, he
reported having gone to two restaurants and projecting bad thoughts toward his parents. This
exercise enabled Brian to disprove the notion that others could hear his thoughts. In addition, he
attended a party in which he reported not feeling socially anxious, but he did consume alcoholic
beverages, against medical advice. Considering that Brian reported that alcohol consumption
minimizes social distress, his anxiety rating is not an accurate reporting based on therapy goals.
In addition, alcohol consumption can be conceptualized as a safety behavior to avoid feelings of
anxiety.
Session 9 continued with an in vivo exposure that consisted of riding the subway with the
therapist. Brian reported his pre-, peak-, and post-SUDS as 45, 50, and 0, respectively, with no
difficulty after the exposure, indicating habituation. For homework, he was assigned to go to the
movies, ride the subway to his next appointment and write a one-page speech to practice in ses-
sion. As he desired to return to school, the speech assignment was chosen because it was some-
thing he would need to do in a classroom setting.
At Session 10, Brian reported completing most of his homework and continued to demon-
strate marked improvement. Assigned homework was to continue in vivo exposures, go to the
movies, outward thinking, and behavioral activation assignments.

Treatment Sessions 11 to 20
By Session 11, Brian was able to ride the subway alone, having practiced this for homework,
and in fact rode the subway to session with his father (pre-, peak-, and post-SUDS were 50, 50,
and 20, respectively). In addition, he attended a movie once, practiced having negative thoughts
toward others, and completed a one-page speech about his dog, but he forgot the speech at
home. When reassessed, he reported less anxiety but reported feeling depressed because he had
Williams et al. 333

been out of medication for a few days. Brian gave his speech to the therapist in an otherwise
large empty room with a pre-, peak-, and post-SUDS score of 60, 90, and 40, respectively.
When he attempted to deliver the speech a second time (peak SUDS of 80), Brian reported that
he was sweaty and did not like being the center of attention. He then expressed that he would
like to prepare first with note cards. As such, homework was assigned for him to continuing
taking the train, give a talk to other people such as friends with note cards (5 times), and attend
a movie (1-2 times).
At Session 12, Brian reported that he did not like riding the train because he was anxious
about missing his stop; his reported SUDS for pre, peak, and post are 65, 75, and 40, respectively.
In addition, he admitted being avoidant about giving the speech to others but committed to give
the speech to his parents first. Homework assigned was to read a handout about anxiety and
panic, practice the speech in front of his parents, and go to the movies.
At Session 13, a review of the psycho-educational material on anxiety and panic was con-
ducted with Brian. This is an important part of therapy that provides a knowledge base about the
nature and the most common findings regarding the presenting problem, and it helps to increase
habituation. As such, four mantras were derived to assist with Brian’s cognitive restructuring
process: (a) small stupid things I do people don’t notice, (b) people aren’t focused on me even
though it feels like it, (b) people can’t tell when you’re nervous, and (d) keep practicing and it
gets easier. Generally, Brian reported notable mood improvement in part due to medication com-
pliance; however, he reported that he still sometimes heard voices and suspected that others could
hear his thoughts. In addition, he traveled to session via train with pre-, peak-, and post-SUDS of
75, 75, and 0, respectively. Despite Brian’s marked progress with the public transportation expo-
sure, he attributed most of the worry to concerns over missing his stop or losing his ticket. As
such, homework assigned reinforced practicing in vivo exposures, continue traveling on the
train, practice giving a speech to others, and attending a movie (1-2 times).
Brian demonstrated more motivation as evidenced by completing homework assignments and
compliance with medication. By Session 14, Brian arrived to session via train and reported SUDS
for pre, peak, and post as 30, 35, and 0, respectively. He also reported that giving a speech in front
of his parents was less challenging after having practiced 3 times. He then practiced giving the
speech in a video-recorded, empty room in front of the therapist; Brian reported SUDS for pre,
peak, and post as 50, 65, and 10, respectively. The therapist told Brian that the recorded exposure
would be reviewed in Session 15. Homework was assigned to continue riding public transporta-
tion to session, to attend a concert, and to practice going to the movies.
At the subsequent session, Brian reported having practiced watching a movie at the theater
with SUDS of 15 for pre-, peak-, and post-exposure. He also arrived to session by train with
SUDS for pre, peak, and post reported at 20, 35, and 20, respectively; a decrease in SUDS rating
may be due to the fact that he fell asleep on the train—an indication of low anxiety. Generally,
Brian demonstrated improvement and continued to be motivated to complete treatment. Following
homework review, an in vivo exposure was conducted that involved the review of Brian’s
recorded speech to a small group (three confederates). In addition, he held a 15-min discussion
after the review of his recorded speech. Brian reported SUDS ratings for pre, peak, and post at
50, 60, and 0 respectively. Confederate feedback in concert with Brian’s predictions were col-
lected by the therapist, to be discussed with him in Session 16.
For homework, Brian was asked to write and practice a new speech in the form of an imaginal
exposure. An imaginal exposure is a patient-developed script that captures his or her concerns
when the event is happening; often delivered in the second person, present tense by the therapist
(“You are . . . ”). The patient can be asked to write a script for homework, or the patient and the
therapist can create it in the session. An imaginal exposure can be useful in patients with SAD
when patients hold a feared consequence that is unlikely to occur and yet so powerful that it feeds
avoidance behavior (e.g., Vrielynck & Philippot, 2009). The exposure should contain much
334 Clinical Case Studies 14(5)

detail, including all the senses (sight, hearing, smelling, etc.), as well as how patients feel and
think throughout the story.
In Session 16, Brian arrived to therapy without his imaginal exposure homework; however, he
practiced other social situations listed on his hierarchy: dinner with friends, talking with a new
female friend, and attending a party. An imaginal exposure of a failed speech was drafted in ses-
sion. Brian gave a pre-SUDS rating of 20 before reading the draft into a microphone for record-
ing. The purpose of drafting the worse-case scenario is to afford the patient a simulated experience
to elicit and heighten anxiety surrounding events they worry could happen well into the future
(e.g., “If I keep saying stupid things in social situations, people will keep reacting to me by berat-
ing and rejecting me for the mildly stupid things I say, and therefore I’ll be alone forever”).
In Session 17, the imaginal exposure of the failed speech was recorded twice. Brian reported
that it did not make him feel anxious, with a reported peak SUDS score of 35; however, he stated
that the exposure made him feel depressed, as such, the imaginal exposure was abandoned. The
therapist shifted the discussion to the feedback regarding the recorded speech exposure and small
group discussion conducted in Session 15. Brian’s predicted performance and predicted audience
reviews obtained an average rating of 5 on a scale of 0 to 10. In addition to Brian’s predictions,
confederates also provided ratings for his speech delivery that were on average, 5 to 6 points
higher than his predictions averaged before delivering the speech. Overall, the confederates com-
plimented Brian on his performance, speech design, and the amount of content addressed. As
stated earlier, it is efficacious to compare patient predictions with confederate ratings to aid the
patient in disproving his or her automatic thoughts. Brian learned from the exposure that he could
deliver an adequate speech and that it was unlikely that others would ridicule him. For home-
work, Brian agreed to draft a new speech to practice with family members and to ask three
women for their phone numbers.
For Session 18, Brian reported that he did attend a concert (pre-, peak-, and post-SUDS scores
at 50, 80, and 40, respectively) but did not complete other assignments. However, the patient
participated in an in vivo exposure that involved the patient writing a long poem to recite in front
of an audience of four people and the therapist, including a question and answer session at the
end (pre-, peak-, and post-SUDS scores at 55, 70, and 20, respectively). Brian demonstrated great
courage by reciting another poem impromptu and subsequently answered questions. Concluding
the exposure, he reported that he felt that he could present in a classroom setting. Again, confed-
erate ratings were collected and rated very highly on a 0 to 10 scale. On average, Brian was rated
at 9 on his overall performance, and when asked “how anxious did Brian appear,” confederates
rated, on average, a 2.
Furthermore, as evidence by Brian’s marked improvement and few residual symptoms of
social anxiety, the patient and therapist discussed returning to school. Homework assigned con-
tinued to focus on social skills development; Brian was assigned to ask to several females for
their phone numbers and to continue to practice other exposures.
At the beginning of Session 19, Brian reported that he did not complete his homework due to
feeling depressed the previous week. Despite the feelings of depression, Brian had a few remnant
symptoms of SAD. Furthermore, the agreement was concluded to terminate treatment after fur-
ther review of the confederates’ feedback, and subsequently, treatment goals were reviewed.
Homework assigned involved an additional exposure to start conversations with random females
at a bookstore 2 to 3 times with 5 to 10 people; Brian predicted a pre-SUDS score of 45. Last,
follow-up sessions were planned to discuss progress when patient attended school.

Final Session
The final session consisted of discussion of progress, helpful techniques learned in therapy, and
relapse prevention. Brian’s parents attended the final session and expressed concerns about his
Williams et al. 335

progress. Although his symptoms of SAD were greatly improved, they were concerned about his
unwillingness to attend school full-time and increase his work hours. In addition, his mother felt
that he was not helpful around the house and that she needed to expend too much energy to help
him organize his activities. In light of the familial distress experienced due to Brian’s limitation,
recommendations to attend family therapy and management for ADHD symptoms were
suggested.
Moreover, despite his parents’ request, Brian expressed an autonomous decision to attend
school part-time first then progress to a full-time class, with a work schedule to ensure success in
his performance. In addition, Brian felt that a full-time school and work may overwhelm him. As
such, he made a plan to enroll in one to two courses at a local community college. The therapist
supported his plans. Follow-up sessions were planned to monitor symptoms while attending
school and working.

Evaluation of Outcome
The patient reported that he no longer was anxious in social situations, and the therapist noted
that he made significant progress in decreasing his anxiety throughout treatment. In addition,
Brian’s scores on clinician-administered interviews and self-reports demonstrated a consistent
reduction in anxiety and related symptoms throughout treatment, with all mood and anxiety mea-
sures having moved into the normal range. His LSAS score dropped steadily, with a total score
of 129 at intake, 72 at mid-treatment (Session 10), and 25 at post-treatment (Session 21). Brian’s
SPWSS score decreased from a total score of 7.2 at intake, to 4.3 at mid-treatment, to 1.5 at post-
treatment (see Figure 1). In addition, his scores on the SPIN (see Figure 2) also decreased with
treatment, from 42 at intake, to 19 at mid-treatment, and finally, to 7 at post-treatment. Brian’s
report of symptoms of depression, as measured by the BDI (see Figure 3), mirrored the trends
with this anxiety, with a score of 17 at pre-treatment, 9 at mid-treatment, and 8 at post-treatment.
Also of note, his paranoia decreased, with an IHS score of 44 pre-treatment and 25 post-treat-
ment. His overall quality of life increased, with a Q-LES-Q score of 44 pre-treatment and 53
post-treatment, indicating a large improvement of 11.3%.

8 Complicating Factors
Although Brian entered therapy reporting that his depression symptoms had improved signifi-
cantly in the past few years, he still experienced moderate depression. As noted previously,
Brian’s symptoms of depression were largely conceptualized as the result of social avoidance
related to SAD but may have also been related to schizophrenia. Brian’s specific symptoms of
depression included becoming exhausted easily, which caused him to exert strong efforts to
complete routine tasks. He also was discouraged about his past failures, had difficulty making
decisions, and had trouble sleeping. In addition, Brian acknowledged that he often isolated him-
self from others, which made him feel more depressed. He was encouraged to force himself to
spend time with friends and family, and he often reported this helped to relieve his symptoms of
depression.
Another factor that complicated Brian’s case was his resistance to engaging in exposures,
evident since Session 2. After watching a video of himself engaging in conversation as part of the
safety behavior experiment, he became depressed and said that he wanted to skip that session’s
planned exposure. He continued to resist participating in exposures, both in-session and with
those assigned for homework, due to their aversive nature. To increase compliance, the therapist
checked homework completion each session, praised him for completed homework, and regu-
larly emphasized the importance of completing homework. On occasions in which Brian did not
complete assigned homework, the therapist guided Brian in problem solving any barriers to
336 Clinical Case Studies 14(5)

8
7

SPWSS Total Score 6

5
4
3
2
1
0
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21
Session Number

Figure 1.  Self-focus and symptom severity as measured by the SPWSS.

Note. SPWSS = Social Phobia Weekly Summary Scale.

50
45
40
35
Total SPIN Score

30
25
20
15
10
5
0
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21
Session Number

Figure 2.  Fear, avoidance, and physiological arousal associated with social anxiety as measured by the
SPIN.
Note. SPIN = Social Phobia Inventory.

completing the task, and the task was re-assigned. Although the patient did not complete all
exposures assigned for homework, he completed enough of the exercises to lead to symptom
improvement.
Finally, Brian’s drinking habits disrupted therapy. On one occasion, he drank alcohol heavily
with friends the night before a session and reported to the session hungover. Brian justified his
alcohol use as a means to relax (not feeling anxious) in social situations (e.g., parties or talking
to women). Although alcohol afforded Brian temporary relief in social events, the benefits were
short-lived. It is not uncommon that alcohol and other substances may be used to alleviate symp-
toms of anxiety (Fröjd, Ranta, Kaltiala-Hein, & Marttunen, 2011); thus, alcohol use disorders are
frequently comorbid with SAD (J. D. Buckner et al., 2008).
Williams et al. 337

20
18
16
14
Total BDI Score 12
10
8
6
4
2
0
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21
Session Number

Figure 3.  Depressive symptomology as measured by the BDI.

Note. BDI = Beck Depression Inventory.

9 Access and Barriers to Care

Brian overcame a number of barriers to access the psychological care that he needed. The lack of
evidence-based treatments practiced in the community in general and particularly for those with
psychosis (for a review, see Berry & Haddock, 2008) was a barrier to his treatment.
Pharmacotherapy is frequently presented as the sole intervention for individuals with psychosis,
despite the growing empirical evidence demonstrating the efficacy of psychotherapy in this pop-
ulation (e.g., Morrison et al., 2012). Although Brian was fortunate to have access to empirically
based psychotherapy delivered at a leading university medical center, the distance to the treat-
ment facility presented a modest barrier to care, as the patient had to travel about 30 miles from
his home for each session. Nonetheless, the treatment venue was easily accessible by both public
and private means. Brian would not have been able to obtain treatment without the financial and
logistical support of his parents, who paid for his treatment and accompanied him to early ses-
sions. His limited finances (due to his psychopathology) and the nature of his psychopathology
(fearfulness of people) could have created an impassible barrier to treatment in and of itself.
Brian also reported having a negative experience with a previous treatment provider, who he said
had refused to see him after he reported to her that he had been experiencing suicidal ideation.
Although it would be expected that Brian would have difficulty seeking treatment after this inci-
dent as well as difficulty developing therapeutic alliances and a sense of trust with future thera-
pists, he and the current therapist were able to develop a fairly strong therapeutic alliance that
served as the foundation for treatment.

10 Follow-Up
About 2 weeks after the conclusion of treatment, Brian made a suicide attempt and was hospital-
ized for 1 week. He attributed his stress to his challenging relationship with his parents. As an
integral part of his support network, Brian’s parents exhibited a powerful influence on his func-
tioning. Unfortunately, based on the previous session’s discussion with Brian’s parents, it
appeared they may have interacted with Brian in ways that perpetuated his distress and increased
his risk for relapse. Although they were supportive in paying for and transporting him to treat-
ment sessions, at times Brian’s parents appraised his behavior in ways that were discordant with
338 Clinical Case Studies 14(5)

his marked improvement and seemed to demonstrate little understanding of his limitations. These
factors appeared to have contributed to his parents’ seemingly low levels of empathy and high
expectations.
In hindsight, the conflict Brian experienced with his family may have been prevented or mini-
mized by involving his parents more throughout the treatment process. The clinic where Brian
received care specialized in very focused treatments for anxiety-related conditions, but clinicians
who are able to provide a broader range of services should dedicate time to understanding dynam-
ics of the relationship between the patient and parents, and also on helping the parents to under-
stand the limitations and difficulties of such patients. In fact, evidence-based treatment
recommendations for individuals with schizophrenia who have regular contact with family mem-
bers include family-based interventions (Dixon et al., 2010). These recommendations are based
on findings of such interventions showing benefits to patients and families, including increased
medication adherence and reduced psychiatric symptoms (e.g., Pitschel-Walz, Leucht, Bäuml,
Kissling, & Engel, 2001).
Nevertheless, a few months later, this crisis had resolved, and Brian had enrolled in four
courses at a local community college. He agreed to return to therapy if he perceived that he was
having additional difficulty with his social anxiety.

11 Treatment Implications of the Case

The successful treatment of Brian’s SAD provides evidence to support CBT as an effective treat-
ment for SAD in patients with symptoms of psychosis. A common assumption by some therapists
is that those with psychosis will not have the cognitive resources to successfully engage in CBT.
However, Brian was able to grasp the treatment model and engage in cognitive restructuring
similar to patients without psychotic symptoms. Of course, treatment for Brian required more
care, as described above with the complicating factors. However, with the progression of therapy,
Brian’s autonomy gradually burgeoned with his consistent commitment to actively participate,
practice, and complete assignments to accomplish his treatment goals. In addition, he reported
less alcohol consumption, greater medication compliance, and increased behavioral activation,
which is believed to be responsible for the decline in symptoms.

12 Recommendations to Clinicians and Students

It is important to ensure that all medications for psychotic and depression symptoms are stable
before beginning CBT for SAD. Treatment of SAD in patients with psychotic disorders is already
challenging, given the extra attention that must be paid to symptoms such as auditory hallucina-
tions and paranoia. If these symptoms are not well-managed, they can take precedence over the
SAD symptoms, and treatment may be less effective. For this reason, it is critically important that
such patients be followed by a regular psychiatrist. Considering that Brian struggled with schizo-
phrenia and that there is entangled symptomology with his SAD, it can be helpful to engage in
CBT for the comorbid disorders and medication compliance. If both primary and comorbid
symptoms are attended to simultaneously, the treatment process for SAD may resolve comorbid
depression symptomology and paranoia associated with schizophrenia.
Of similar importance is the implementation of family therapy. Family counseling can facili-
tate a balance between the patient’s current stages of change, realistic expectations, and positive
familial support. Therefore, it is particularly advantageous to encourage family therapy to ensure
a healthier sense of support for the patient, educate the family unit about the patient’s condition
and goals, and provide an outlet for distressed family members.
For individuals presenting with primary problems relating to schizophrenia, CBT should be
considered, considering the growing literature base demonstrating its efficacy (Morrison et al.,
Williams et al. 339

2012). Many of the same techniques used in a general course of CBT are central components of
CBT for schizophrenia. However, the authors also identify important adaptations of psycho-
therapy for this population, including slower pacing of sessions, shorter duration of sessions that
occur with more frequency, and written summaries of sessions for patients. Furthermore, the
authors suggest making initial goals achievable and “unambitious.”
For individuals with well-managed schizophrenia who present for treatment of anxiety symp-
toms, the empirical literature offers a paucity of evidence needed to provide definitive interven-
tion guidelines. However, this case study suggests that existing evidence-based treatments,
delivered with necessary adaptations, can produce successful outcomes. Brian’s case illustrates
that with persistent work and careful attention, patients with SAD can improve with CBT, despite
complicating factors, such as psychosis, alcohol abuse, MDD, and family conflict.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or
publication of this article.

Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.

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Author Biographies
Monnica T. Williams, PhD, is an assistant professor in the Department of Psychological and Brain Sciences
at University of Louisville and the director of the Center for Mental Health Disparities. She conducts
research on the assessment and treatment of anxiety disorders and multicultural issues.
Michelle C. Capozzoli, MA, is a doctoral student in the Clinical Psychology Training Program at the
University of Nebraska–Lincoln. Her research interests include factors related to the development and
maintenance of anxiety disorders.
Erica V. Buckner, BA, is a doctoral student in the Department of Psychological and Brain Sciences
Clinical Psychology Program at the University of Louisville. Her research investigates the emotive and
interpersonal stability of urbanized ethnic minorities, the sub-cultural identity of minority adolescents
indigenous to low socio-economic status communities endemic to violence, and the exploration of cultur-
ally sensitive treatment mechanisms.
David Yusko, PsyD, is the clinical director at the Center for the Treatment and Study of Anxiety in the
Perelman School of Medicine at the University of Pennsylvania. He specializes in prolonged exposure therapy
for posttraumatic stress disorder, exposure and response prevention for obsessive-compulsive disorder, and
cognitive-behavioral therapy for social anxiety, panic disorder, specific phobias, and generalized anxiety.