1. F40.10, Social Anxiety Disorder

   1. Avoids social situations

   2. Social situations extremely anxiety inducing

   3. Lasted more than 6 months

   4. Significant function impairment

   5. Believes others are judging him

   6. Z codes for consideration: Z62.898, Child affected by parental relationship distress. Z63.5 Disruption of family by separation or divorce. Z59.71, Insufficient health insurance.

2. Majority of people client is comfortable around are also Argentinian. Culture also impacts the way people perceive coping mechanisms. Misunderstanding phrases or cultural shame in a society that is majorly not representative of his culture.

3. F32.9 Major Depressive Disorder, unspecified, F43.23 Adjustment Disorder with mixed anxiety and depressed mood

4. CBT, Family therapy, mindfulness, ERP

5. Build community around client's identified interests. Ex.) he likes to draw, try drawing outside with peers to foster connection as a homework assignment. Also involving client's interests into sessions. Ex.) construct a building of support via his architect interest. Create a value assessment with client to help visualize and verbalize hierarchy and values.

1. What symptoms indicate an anxiety disorder, and which specific disorder(s) might be present? Include the diagnosis.

Primary Diagnosis:

F40.10 Social Anxiety Disorder

Secondary Diagnosis:

F33.1 Major Depressive Disorder, Recurrent Episode, Moderate

Andrew presents with numerous symptoms consistent with a severe anxiety disorder, including:

• Intense fear of social and performance situations, particularly crowded environments, large class sizes, and interactions where others may look at or judge him.

• Marked physiological arousal, including sweating, racing heart, and trembling when attempting to enter school.

• Avoidance behaviors, including total school refusal for two months, avoidance of phone calls, avoiding public places (malls, concerts), and limiting social interactions to familiar individuals.

• Cognitive distortions, such as assuming others will “look at me and laugh,” despite recognizing this may be irrational.

• Longstanding functional impairment, including chronic absenteeism since middle school and inability to engage in normative developmental activities.

These symptoms meet DSM-5-TR criteria for Social Anxiety Disorder. His anxiety is primarily driven by fear of negative evaluation, humiliation, and public scrutiny—hallmark features of this disorder.

A secondary, provisional diagnosis of Major Depressive Disorder, recurrent episod, moderate, may also be appropriate given chronic sadness, loneliness, crying spells, social withdrawal, sleep disturbance, appetite disruption, and intermittent suicidal ideation without plan or intent.

2. How do cultural beliefs and coping styles influence the expression of anxiety?

Andrew’s cultural background as an Argentinian adolescent living in the United States appears to shape both the expression of his anxiety and his coping responses:

Cultural Factors

• Acculturation Stress: Moving to the United States at age 10 and navigating a new language and social environment may have heightened sensitivity to judgement and fear of “saying something stupid or wrong.”

• Familismo: Strong cultural emphasis on family cohesion may increase pressure to avoid behaviors perceived as embarrassing or burdening to others.

• Stigma: Latinx cultures often carry stigma around mental health struggles. This may contribute to Andrew masking distress (smiling while discussing painful topics) and not sharing feelings with friends or family.

• Shame and socioeconomic identity: His embarrassment when describing his mother’s job and changes in family finances suggests internalized shame, which amplifies social evaluative fears.

Coping Styles

• Avoidance coping: Avoiding school, phone calls, and social events regulates anxiety short-term but reinforces symptoms.

• Reliance on culturally familiar peers: His comfort with older Argentinian friends reflects coping through cultural continuity.

• Substance use: Drinking 2–3 beers to self-medicate anxiety at parties indicates emerging maladaptive coping.

• Passive coping: Staying under covers, waiting to fall asleep, and watching television all day reflect withdrawal-based coping, often seen when anxiety co-occurs with depression.

Culturally responsive assessment should validate these stressors and integrate cultural strengths, including community belonging and familial support.

3. What are possible differential diagnoses?

Several differential diagnoses should be considered based on symptom overlap:

PTSD – Ruled Out

While Andrew has experienced stressors, immigration, parental divorce, and perceived abandonment,there is no Criterion A trauma reported such as exposure to actual or threatened death, serious injury, or sexual violence. Symptoms are not trauma-driven.

Obsessive-Compulsive Disorder – Unlikely

He experiences intrusive social worries but no compulsive behaviors, rituals, or repetitive mental acts intended to neutralize anxiety.

Generalized Anxiety Disorder – Rule Out

His worry is situation-specific (social evaluation) rather than across multiple domains of life.

Panic Disorder – Rule Out

He exhibits physiological arousal but no recurrent unexpected panic attacks.

Agoraphobia – Consider but Unlikely

His avoidance of public spaces appears rooted in fear of judgement, not fear of being unable to escape or fear of panic symptoms.

Autism Spectrum Disorder – Unlikely but assess

Although he has limited eye contact, his developmental history is normal, and his avoidance appears anxiety-based, not related to social communication deficits.

Medical Conditions

A medical workup is recommended to rule out any potential diagnosis that could account for symptoms.

4. What interventions could help the client manage anxiety?

A culturally informed, evidence-based treatment plan may include:

— Cognitive Behavioral Therapy for Social Anxiety

• Identify and restructure cognitive distortions (e.g., “Everyone is laughing at me”).

• Teach coping skills for physiological symptoms (breathing, grounding).

• Build emotion regulation and distress tolerance.

— Graduated Exposure Therapy

• Develop hierarchy of feared situations (e.g., sitting in car near school → walking campus during off hours → attending class for brief periods).

• Incorporate in-session role plays, social skill rehearsal, and real-life exposures.

• Emphasize eliminating “safety behaviors” like avoidance or alcohol use.

— Mindfulness-Based Interventions

• Teach present-focused awareness to reduce rumination and anxiety spirals.

• Integrate culturally congruent practices (e.g., Spanish-language guided meditations).

— Sleep hygiene and behavioral activation

• Structure daily routine to improve sleep cycles.

• Increase engagement in meaningful activities (drawing, social outings, exercise).

— Family involvement

• Psychoeducation for mother around anxiety, avoidance cycles, and supportive communication.

• Explore cultural narratives around shame, success, and emotional expression.

— Strengthening prosocial peer connections

• Gradual reintroduction to age-appropriate socialization.

• Encourage reconnection with school-based supports.

— Consider psychiatric evaluation

·      If depression or anxiety symptoms continue to impair functioning, medications such as SSRIs may be helpful.

5. How would you collaborate with the client to identify strengths and build resilience?

A strengths-based, collaborative approach might include:

Exploring Internal Strengths

• Highlight his insight (“I know people are probably not saying anything”).

• Acknowledge his persistence in completing homework despite school refusal.

• Affirm his long-term goals (becoming an architect).

Identifying Cultural and Community Strengths

• Build on his supportive Argentinian peer network.

• Incorporate his bilingual identity as a strength, not a deficit.

• Utilize culturally resonant metaphors and values (family, perseverance).

Supporting Positive Identity Development

• Validate his feelings about immigration, identity, and family changes.

• Explore narratives of resilience within his cultural background.

Co-Creating a Resilience Plan

• Set small, achievable goals that gradually increase his autonomy.

• Use motivational interviewing to elicit values (“the happy kid I used to be”).

• Implement routines that support behavioral activation and self-efficacy.

Collaborative Safety Planning

• Continue monitoring suicidal ideation while reinforcing coping resources and protective factors (mother, brother, friends, future aspirations).

Through strengths-based collaboration, Andrew can begin to understand his anxiety not as a personal failure but as a treatable condition, and he can reconnect with the parts of himself that he identifies as strong, creative, and capable.

F40.10 - Social Anxiety Disorder

Andrew meets all of the criteria for Social Anxiety Disorder. He experiences extreme fear and avoidance in social settings persistently, particularly in school and interactions with peers. This disorder causes significant impairment, due to him not being able to go to school and lack of sleep. He fears scrutiny and worries about crowds laughing or speaking negatively about him. 

2. How do cultural beliefs and coping styles influence the expression of anxiety?

Andrew’s coping style is avoidant, which compounds his fear of social situations and people. He feels more comfortable around those who share the same culture as him. He views himself as an outsider around those with a different culture than him. 

3. What are possible differential diagnoses (e.g., PTSD, OCD, medical conditions)?

Agoraphobia, Separation Anxiety Disorder, Generalized Anxiety Disorder

4. What interventions could help the client manage anxiety (e.g., mindfulness, exposure therapy)?

Healthy coping skills, exposure therapy (gradual exposure lattering techniques), mindfulness, CBT (reframing), Rationale Emotive Therapy, DBT (de-stress tolerance and emotional regulation), support group

5. How would you collaborate with the client to identify strengths and build resilience?

Motivational Interviewing (setting clear goals), skill building, hone in on professional aspirations, validation (normalizing fear), building a support network

F40.10 Social Anxiety Disorder

#1 -

•       Fear of attending school or other social situations

•       Began last year when he was in middle school = therefore lasted longer than 6 months

•       Showcases intense fear of negative reactions (embarrassment)

•       Physiological reactions = sweating, heart racing

•       Disrupted sleep pattern = difficulty falling asleep until 3am

•       Sadness, loneliness, crying

•       Eating habits (consumes large amount of food)

•       Intermittent suicidal ideations (no intent or plan)

•       Use of alcohol to cope

•       Functional impairment, has not attended school in 2 months

#2 -

Andrew has an Argentinian background. He recently moved to the United States approximately 5 years ago. Therefore, he may have stressors related to acculturation due to immigration. This may influence his fear of not belonging to being accepted by peers. His mother also reports he started being withdrawn when his father left, approximately 3 years ago. This may have some implications on his beliefs around family and cause some distress or intense emotions surrounding that particular situation. Mental health is also a stigma in Latin American cultures, therefore symptoms can be interpreted as being "lazy" rather than concerning.

#3 -

Major Depressive Disorder: prolonged period of time of loneliness, sadness, and crying spells. He also reports being socially isolated and does not want to share or talk about his feelings to anyone.

PTSD: He immigrated to the United States five years ago, there could be potential traumatic events related to his symptoms.

#4-

CBT: challenge negative thoughts regarding peer judgement

Exposure Therapy: slowly expose Andrew to normal school customs (e.g., riding the bus, going to class, etc.) with the support of a school social worker.

#5 -

As a social worker, we would use a strength-based approach to highlight Andrew's strengths while also using new interventions. We would also collaborate with his mother to create goals to get Andrew to attend school. We must also build a collaborative team with his teachers, school social worker, and school counselor to ensure they are helping him develop coping skills to help ease his anxiety symptoms at school. Lastly, Andrew seems close to his Argentinian culture, therefore we would use his cultural background to empower his self autonomy and sense of self while integrating into a new school environment.

1. What symptoms indicate an anxiety disorder, and which specific disorder(s) might be present? Include the diagnosis. 

Social Anxiety Disorder (F40.10)

• Symptoms:

  • Marked fear about attending school and interacting with peers

  • Persistent anxiety surrounding how appearance is perceived by others

  • Avoidance of social situations and interactions due to fear of saying something "stupid" or "wrong"

  • Physical symptoms of anxiety

    • sweating excessively

    • minimal eye contact

    • heart racing

  • Inability to execute daily functioning (has been unable to attend school for the past two months)

  • Difficulty sleeping

  • Difficulty eating (irregular habits)

  • Withdrawal

  • Feelings of isolation and hopelessness

    • Occasional feelings of suicidal ideation (no intent or plan)

    • Does not share his feelings with anyone in his life

2. How do cultural beliefs and coping styles influence the expression of anxiety?

Cultural background may influence the way in which Andrew expresses his anxiety. Due to stigmatization in the Hispanic culture (especially for men), speaking about mental health struggles may lead to a sense of feeling weak or produce shame in the individual Andrew would be speaking with. Culturally, the client may be downplaying his emotions and experiencing difficulty verbally expressing them. 

3. What are possible differential diagnoses (e.g., PTSD, OCD, medical conditions)?

• Generalized Anxiety Disorder - chronic worry about multiple domains

• Panic Disorder - presents with somatic symptoms

• Major Depressive Disorder - reports sadness, withdrawal, and hopelessness

4. What interventions could help the client manage anxiety (e.g., mindfulness, exposure therapy)?

• Cognitive behavioral therapy (with an emphasis on building a toolbox of coping skills for Andrew to rely on, like cognitive reframing)

• Dialectical behavioral therapy (distress tolerance, interpersonal effectiveness, etc.)

• Joining a social anxiety support group

• Medication (SSRI, SNRI, etc.)

• Potential exposure therapy (if all other options are exhausted or if client is interested)

5. How would you collaborate with the client to identify strengths and build resilience?

• Strengths-based approach (highlight strengths and utilize protective factors)

• Family involvement in treatment

• Emphasize patient autonomy

• Employ cultural humility when developing treatment goals and coping skills

• Form smaller, manageable treatment goals that are realistic to his needs

1. What symptoms indicate an anxiety disorder, and which specific disorder(s) might be present? Include the diagnosis.

Some of Andrew’s symptoms that indicate an anxiety disorder are: intense fear of social evaluation, physiological anxiety symptoms and avoidance behaviors. He also reports extreme fear that classmates will look at him, laugh at him or make fun at him, he avoids large crowds, public transportation, malls, concerts, answering the door, and especially school, where he has been unable to attend a single day this year. When he tries to go to school he presents symptoms such as sweating, nervousness, and a racing heart, and he experiences persistent anticipatory worry about saying something “stupid” or being judged negatively.

Based on these symptoms, the most appropriate diagnosis is F40.10 Social Anxiety Disorder, severe. Other additional codes to consider are:

Z55.8 – Other Problems Related to School

Z60.0 – Phase of Life Problem

Z63.5 – Disruption of Family by Divorce

Z60.3 – Acculturation Difficulty

Z59.6 – Low Income

2. How do cultural beliefs and coping styles influence the expression of anxiety?

The client is an immigrant from Argentina. He expresses that he is only comfortable when he is around people he knows which usually consist of family and his Argentinian community. His mother is mainly Spanish speaking. The client watches Argentinian soap operas when he wants to be comfortable. It appears that the client is home sick and wants to feel as safe as he did when he lived in Argentina. Client states he wants to be “The happy kid I used to be when I lived in Argentina”.

3. What are possible differential diagnoses (e.g., PTSD, OCD, medical conditions)?

Other conditions to consider include Generalized Anxiety Disorder, Panic Disorder, and Major Depressive Disorder, though none fully match his presentation. PTSD and OCD are unlikely because he does not report trauma exposure or obsessional thoughts and compulsions. Medical causes such as thyroid issues or sleep disorders should also be ruled out to ensure accuracy.

4. What interventions could help the client manage anxiety (e.g., mindfulness, exposure therapy)?

CBT, Social exposure, skills training (social skills, relaxation techniques, sleep hygiene interventions), school-based interventions, family psychoeducation, monitor depression, sleep and eating patterns, and alcohol use. Consider a pharmacological consultation.

5. How would you collaborate with the client to identify strengths and build resilience?

Collaboration with Andrew to identify strengths and build resilience would involve creating a safe, nonjudgmental space where his emotions and fears are validated and acknowledged. A strengths-based and culturally responsive approach would highlight the abilities already present in his story, such as his insight into his feelings, his continued motivation to keep up with schoolwork, his courage in seeking help despite significant anxiety, and his strong connection to the Argentinian community. Through exploration with empathy and compassion, we could support Andrew in identifying times when he has coped effectively in the past, relationships that feel safe for him, and activities that once brought him joy or confidence. His resilience could be strengthened by building coping skills, reinforcing family and community support systems, and engaging Andrew in collaborative, realistic steps toward his goals. This approach helps Andrew recognize and expand the internal and external resources that can support his healing and development.