508220

research-article2013
Kaufman and Baucom
CCS13310.1177/1534650113508220

Article
Clinical Case Studies
2014, Vol. 13(3) 265­–281
Treating Comorbid Social © The Author(s) 2013
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DOI: 10.1177/1534650113508220
The Challenge of Diagnostic ccs.sagepub.com

Overshadowing

Erin A. Kaufman1 and Katherine J. W. Baucom1

Abstract
Depression and social anxiety disorder (SAD) are two of the most common mental health
conditions, and often occur together. Depression is usually identified as the presenting problem,
which may result in SAD being overshadowed and undertreated among those with this particular
comorbidity. In this case study, diagnostic overshadowing results in successful treatment of
depression but delayed identification of SAD, causing an attenuated anxiety treatment response.
We present recommendations on how clinicians may more thoroughly assess for comorbid
Axis I diagnoses, avoid diagnostic overshadowing, and better integrate treatment approaches
for SAD–major depressive disorder (MDD) comorbidity. Mechanisms underlying cognitive-
behavioral treatments such as behavioral activation and exposure hold particular promise for
promoting improvement in SAD and major depression simultaneously.

Keywords
social anxiety, major depression, cognitive-behavioral therapy, diagnostic overshadowing,
comorbidity

1 Theoretical and Research Basis for Treatment

Social anxiety disorder (SAD) is characterized by a fear of embarrassment or humiliation in
social situations that causes significant distress or functional impairment Diagnostic and
Statistical Manual of Mental Disorders (4th ed., text rev.; DSM-IV-TR; American Psychiatric
Association [APA], 2000). It is pervasive, with a lifetime prevalence rate of approximately 12%,
making SAD the fourth most common psychological disorder in the United States (Kessler et al.,
2005). Without treatment, SAD is typically chronic, and the diagnosis rarely occurs in isolation
(Davidson, Hughes, George, & Blazer, 1994). In fact, many individuals with SAD principally
seek treatment for another mental disorder (Dalrymple & Zimmerman, 2011).
SAD is the most common co-occurring anxiety disorder with major depressive disorder
(MDD), with reported comorbidity rates ranging from 15% to 33% (Belzer & Schneier, 2004;
Zimmerman, Chelminski, & McDermut, 2002). This is not surprising given that MDD and SAD
have a number of overlapping characteristics (e.g., sensitivity to interpersonal rejection, reduced

1University of Utah, Salt Lake City, USA

Corresponding Author:
Erin A. Kaufman, Department of Psychology, University of Utah, 380 S. 1530 E. BEHS 502, Salt Lake City, UT 84112,
USA.
Email: erin.kaufman@psych.utah.edu
266 Clinical Case Studies 13(3)

optimism, hope, and reward sensitivity; low positive-affect; and high levels of self-focused atten-
tion; see Dalrymple, 2012, for a review). These features combine to result in feelings of inade-
quacy and avoidance of interpersonal situations. In particular, low self-esteem has been identified
as a key feature of (Bouvard et al., 1999; Franck, De Raedt, Dereu, & Van den Abbeele, 2007)
and risk factor for both disorders (Clark & Wells, 1995; Gemar, Segal, Sagrati, & Kennedy,
2001). de Jong, Sportel, de Hullu, and Nauta (2012) found a strong association between symp-
toms of depression and social anxiety among adolescents that was largely explained by partici-
pants’ explicit self-esteem, or their deliberate self-evaluative processes. Interestingly, longitudinal
studies show low explicit self-esteem predicts subsequent depressive symptoms (Ormel,
Oldehinkel, & Vollebergh, 2004); however, depressive symptoms do not predict later self-esteem
(Orth et al., 2009). A similar pattern exists in SAD (Acarturk et al., 2009). This indicates low
self-esteem is more likely a contributor to depression and social anxiety rather than a conse-
quence of these conditions.
SAD–MDD comorbidity negatively impacts individuals more than either disorder in isola-
tion. For example, individuals with this diagnostic profile are at risk of developing substance use
problems (Nelson et al., 2000). They are more likely than those with a solitary MDD diagnosis
to experience future depressive episodes, an earlier onset of depression, longer duration and a
greater number of depressive episodes, and intense suicidal ideation (Dalrymple & Zimmerman,
2011). Those with SAD–MDD comorbidity also appear to have greater functional impairment.
They are less likely to marry, attend college, or maintain employment (Alpert et al., 1997).
Affected individuals have poor social functioning, report greater problems in their day-to-day
lives, have worse overall physical health, and seek treatment at higher rates compared with those
with only one of these two diagnoses (Dalrymple & Zimmerman, 2007).
Evidence suggests SAD is a unique risk factor for eventual MDD development beyond the
influence of other anxiety disorders. Specifically, epidemiological studies and research with clin-
ical samples have shown SAD precedes the onset of MDD in approximately 70% to 85% of co-
occurring cases (Belzer & Schneier, 2004). In addition, some research suggests MDD and SAD
may derive from a common etiology. A shared genetic vulnerability to both conditions has been
documented in twin research (Nelson et al., 2000), and family studies show that first-degree rela-
tives of those with SAD have elevated rates of MDD compared with controls (Fyer, 1993).
Although there is a demonstrated link between these two disorders, SAD is frequently over-
looked in those with MDD in psychiatric and primary care settings (Zimmerman & Chelminski,
2003), and may be underrecognized in other venues where lengthy structured interview proce-
dures are difficult or impossible to implement. A survey administered to members of the American
College Counseling Association found the highest percentage of respondents listed additional
resources such as assessment instruments as the one thing that they most desire to improve about
their counseling centers (Smith et al., 2007). This is unfortunate as the presence of SAD among
MDD individuals clearly complicates treatment presentation and impacts clinical care.
Although no treatments have been developed or formally tested targeting SAD–MDD comor-
bidity specifically, treatment outcome research suggests that CBT represents a viable first-line
approach (see Belzer & Schneier, 2004, for a review). SAD is traditionally treated with exposure
and cognitive restructuring techniques to gradually reduce fear and avoidance of social situations
(Turk, Heimberg, & Magee, 2008). Exposure in particular has been demonstrated as an essential
therapeutic strategy for SAD treatment (Borgeat et al., 2009). Meta-analytic studies have consis-
tently demonstrated the efficacy of CBT for SAD, and exposure-based interventions have yielded
the highest effect sizes (e.g., Fedoroff & Taylor, 2001). CBT is also the most studied approach to
treating MDD (Butler, Chapman, Forman, & Beck, 2006) and has a substantial evidence base
(e.g., Hofmann, Asnaani, Vonk, Sawyer, & Fang, 2012). Behavioral activation (BA) is a contem-
porary CBT approach to depression that emphasizes activity scheduling and monitoring (not
unlike exposure treatment) to increase rewarding behavior. BA has been demonstrated to be as
Kaufman and Baucom 267

efficacious as pharmacotherapy and more effective than cognitive therapy alone for severe
depression (Dimidjian et al., 2006; Dobson et al., 2008).
In this article, we present a case where MDD and other complicating factors initially obscured
a SAD comorbidity. We describe how a data-driven case conceptualization functioned to eluci-
date the diagnostic overshadowing in this case and make clinical recommendations for effective
identification and treatment of this combination of disorders. Although MDD and SAD have
overlapping characteristics, evidence indicates that SAD is not alleviated through treatment of
MDD alone and vice versa. We review the limitations of using a sequential treatment approach
for each disorder and suggest an integrative CBT-oriented strategy for future evaluation.

2 Case Introduction
Marion was a 20-year-old non-Hispanic Caucasian female. At the time of treatment, she was
enrolled as a student in large state university, commuting from an outlying city. Her case is dis-
cussed to illustrate challenges accompanying diagnostic overshadowing among Axis I disorders,
and to highlight the importance of a strong case conceptualization. We make recommendations
regarding assessment and treatment for SAD–MDD comorbidity. In particular, suggestions are
made for exploring an integrated treatment approach utilizing overlapping principles from BA
and exposure therapies. Marion’s therapist was a doctoral student in clinical psychology super-
vised by a licensed clinical psychologist. Treatment consisted of weekly individual CBT, specifi-
cally BA and graded exposure during the later portion of treatment.

3 Presenting Complaints
Marion presented to a university student counseling center for treatment of complaints surround-
ing her self-esteem, anhedonia, academic difficulties, social isolation, feelings of worthlessness,
and excessive and inappropriate guilt. Marion would avoid engaging in social activities and
schoolwork. She spent large quantities of time engaging in unrewarding behaviors such as web
browsing (approximately 6 to 8 hr daily). Marion endorsed fleeting suicidal thoughts and passive
morbid suicidal ideation 1 to 2 times per month, yet denied current or previous suicidal intent.
Marion endorsed a history of non-suicidal self-injury by scratching her arm superficially on a
few occasions throughout her life; however, she denied engaging in this behavior for several
months prior to treatment.

4 History
Familial and Social History
Marion was born and raised in the Mountain West region of the United States. She lived with her
family of origin, including her mother, father, and three siblings, the eldest of whom suffered
from low-functioning autism. Marion described herself as an introvert, often preferring to spend
time engaging in solitary activities (e.g., online browsing). She struggled to create friendships
and did not have extra-familial social relationships prior to high school, due in part to home
schooling through her middle school years. She “[felt] like an outsider” among her few friends
since she had known them, and had not seen her closest friends in over a year when she presented
for treatment. In her intake session, Marion identified significant interpersonal problems that
manifested as a lack of meaningful relationships. Indeed, at the beginning of treatment, Marion’s
closest relationship was with her romantic partner whom she had never met in person. Marion
reported “not investing in her relationships” out of a preference for solitude. However, she also
endorsed significant distress over losing contact with established friends. Reengagement with
peers was a goal for treatment.
268 Clinical Case Studies 13(3)

Academic History
Marion was homeschooled by her mother during her elementary and middle school years. She
was initially successful in this setting but lost motivation to study when her younger siblings
began homeschooling and she received less attention. Through her homeschooling, Marion
missed out on important opportunities for social and academic development. This made it diffi-
cult for her to form friendships. Determined to excel so as to gain admission to college, Marion
reinvested in academics during her high school years in a traditional public school setting. She
gained admission to the honors college at her university. At the time of intake, Marion was strug-
gling academically. She had dropped out of the honors college and failed some of her courses. In
fact, she was on the verge of failing two of her three current courses when she presented for
treatment.

Employment History
Marion held several odd jobs throughout her first few years of college, but had difficulty meeting
the expectations for these positions, particularly when they involved assertiveness. This led to a
great deal of stress for Marion and, ultimately, her termination from several positions. For exam-
ple, Marion regularly babysat for a family but was fired for being too lenient with the children.
When she presented to treatment, Marion worked 20 to 40 hr per week as a tele-support techni-
cian for a large company. She found this job extremely stressful, particularly interacting with
disgruntled customers. Approximately once a week Marion became overwhelmed to the point of
tears and ended work early.

Medical and Psychiatric History

Marion denied a history of medical problems, psychiatric treatment, or psychotherapy prior to
her intake.

5 Assessment
Marion completed a brief intake assessment of presenting problems and goals for treatment with
a staff member at the undergraduate counseling center (UCC) prior to assignment to her therapist.
Marion’s background, presenting complaints, current functioning, and goals were further assessed
through self-report instruments and clinical interview over the course of two pre-treatment
assessment sessions with her assigned therapist.

Initial Self-Report Measures

The Depression Anxiety Stress Scale-21(DASS21; Lovibond & Lovibond, 1995) is a screening
tool for identifying, differentiating, and assessing three negative emotional states: depression,
anxiety, and stress. It consists of 21 Likert-style items, with higher scores indicative of higher
levels of distress. The DASS21 has good psychometric properties including strong convergent
validity with other gold standard measures (Lovibond & Lovibond, 1995). At pre-treatment,
Marion’s subscale scores were 24 for depression (severe clinical range), 4 for anxiety (normal
range), and 8 for stress (normal range). Average scores among non-clinical college students are
7.19 (SD = 6.54), 5.23 (SD = 4.83), and 10.54 (SD = 6.94) for depression, anxiety, and stress,
respectively (Lovibond & Lovibond, 1995).
The Beck Depression Inventory (BDI; Beck, Steer, & Brown, 1996) is a commonly used mea-
sure for tracking clinical outcomes, has good to excellent psychometric properties, and is brief
Kaufman and Baucom 269

and easy to administer and score. Furthermore, it appears to be a valid tool for the assessment of
depressive symptoms in adults with social anxiety disorder (Coles, Gibb, & Heimberg, 2001). At
the time of her initial assessment session, Marion scored in the severely depressed range (BDI
composite = 29).
The Rosenberg Self-Esteem Scale (RSES; Rosenberg, 1989) is a 10-item, free, and easily
administered measure of explicit self-esteem (de Jong et al., 2012). The scale has high reliability:
test–retest correlations are typically in the range of .82 to .88, and Cronbach’s alpha for various
samples are in the range of .77 to .88 (Blascovich & Tomaka, 1993; Rosenberg, 1986). While
there are no clinical cutoffs for this measure, lower scores indicate lower self-esteem. Scores
most often range from 10 to 40 in the literature, with college students in the United States having
an average score of 32 and a standard deviation of 5.01 (Schmitt & Allik, 2005; Twenge &
Campbell, 2001). At Session 1, Marion’s score was 14, and she endorsed moderate to severe
problems on each of the 10 items on the scale.
The Working Alliance Inventory–Short Revised (WAI-SR; Hatcher & Gillaspy, 2006; Munder,
Wilmers, Leonhart, Linster, & Barth, 2010) is a 12-item client self-report measure of the thera-
peutic relationship that assesses agreement on the tasks and goals of therapy, as well as develop-
ment of an affective bond. Higher scores on the WAI-SR reflect stronger alliance, and the measure
has good reliability (α > .80) and convergent validity with other gold standard measures. Previous
studies report an average score of 45.6 with a standard deviation of 7.56 (Munder et al., 2010).
At Session 2, Marion’s score was 73.

Pre-Treatment Clinical Interview

Marion’s therapist conducted a semistructured clinical interview during the pre-treatment assess-
ment sessions. Her therapist assessed the following: reasons for seeking treatment; current and
previous functional impairment in family, school, work, and interpersonal contexts; history of
individual and familial psychiatric diagnosis and treatment; criminal activity; substance use;
major medical history; health-related behaviors (sleep, exercise, diet, etc.); coping strategies for
dealing with stress; and risk for suicide and self-injury. Marion endorsed social isolation, yet
attributed this to a personal preference for solitude. Given Marion’s presenting complaints, her
therapist assessed for depression and anxiety. At this time in treatment, Marion did not endorse
elevated symptoms of anxiety on her self-report measures and denied feeling “anxious” or “wor-
ried” in her interview. She described feeling a constant sense of guilt, a loss of interest in activi-
ties she used to enjoy, withdrawing from interpersonal relationships, extreme difficulty
concentrating at work and school, difficulty falling and staying asleep, weight gain, feeling
fatigued often, and occasional thoughts of death. Based on Marion’s questionnaires and clinical
interview, her therapist discussed with Marion each of the nine symptoms of MDD and their
applicability to her life. She met seven criteria and was subthreshold on the other two (depressed
mood, psychomotor agitation/retardation). Marion was given psychoeducation about depression
and BA and agreed to a course of therapy using this approach.

Mid-Treatment SAD Assessment

Later in treatment, when SAD was suspected, Marion was given the SAD section (Section F) of
the Mini International Neuropsychiatric Interview (MINI) version 6.0.0 for the DSM-IV (4th ed.;
DSM-IV; APA, 1994; Sheehan et al., 1998), a brief structured interview with similar reliability
and validity to other gold standard interview measures. Marion endorsed avoidance of social
interactions over the previous month, and extreme difficulty in initiating and maintaining conver-
sations, participating in small groups, speaking to authority figures, attending parties, and public
speaking. However, Marion initially downplayed the severity of her symptoms, claiming they
270 Clinical Case Studies 13(3)

were not impairing enough to warrant attention. While she experienced extreme distress in social
contexts, Marion did not view this as particularly interfering with her day-to-day life as she was
actively avoiding situations that induced discomfort.
Her therapist engaged in an in-session role-play with Marion (described below) to evaluate
her level of discomfort in social contexts, and Marion was very surprised to find how difficult
this exercise was for her. Her therapist also framed SAD symptoms in terms of problems Marion
had already brought up during treatment such as her social isolation, her extreme discomfort at
work, and so on. Following the role-play and discussion, Marion determined these problems had
in fact significantly impacted her academic and social performance. After SAD was brought to
her attention, Marion also described further symptoms she had previously attributed to her intro-
verted nature. For example, she experienced extreme difficulty engaging in classroom discus-
sions and presentations and indicated this negatively affected her self-esteem (e.g., “I feel
unintelligent”). She also described avoiding new friendships, yet attributed this to personal pref-
erence for solitude.
The Social Interaction Anxiety Scale (SIAS; Mattick & Clarke, 1998) is a 20-item Likert-type
scale measure of social phobia with excellent psychometric properties (internal consistency
Cronbach’s α = .94; test−retest reliability Cronbach’s α = .92). The SIAS discriminates SAD
from other anxiety disorders. The SIAS was administered to Marion once (Session 7) to confirm
a comorbid SAD diagnosis (in conjunction with the MINI). Marion’s SIAS score was 56, indicat-
ing high levels of social anxiety (among females with social phobia M = 33.4, SD = 16.4; Mattick
& Clarke, 1998).

6 Case Conceptualization
Marion’s case was conceptualized using Persons’ (2008) case formulation approach to CBT. This
ideographic method encourages the flexible application of CBT to account for individual clients’
needs. Importantly, Persons emphasizes a data-driven approach wherein the therapist continually
collects and evaluates new information, works collaboratively with the client, and adjusts the
overall case conceptualization in light of new information. While empirically supported treat-
ments (ESTs) target single disorders, an effective case conceptualization allows the therapist to
think flexibly, outside the limits of diagnostic criteria. In addition, a solid case formulation aids
the therapist’s decision making for many situations not typically covered in treatment manuals
(e.g., comorbid disorders, treatment non-adherence, problems with the therapeutic alliance). The
case-level formulation proposes hypotheses about the mechanisms causing individual client
problems, the precipitants activating these mechanisms, and the origins of said mechanisms.
Treatment is informed by evidence-based theories and approaches, including ESTs. In Marion’s
case, the use of the case formulation approach aided in identification and treatment of her comor-
bid SAD.
Initially most of Marion’s presenting complaints appeared closely tied to depression. Her
initial assessment scores (e.g., BDI-II, DASS21) and clinical interview supported this diagnosis.
MDD was therefore used as Marion’s “anchoring disorder” (Persons, 2008) in our case formula-
tion. An anchoring diagnosis accounts for the largest number of client problems, explains the
problems that interfere most with client functioning, and provides the best account for how client
problems are related. In addition, the anchoring disorder provides a helpful starting place for the
case formulation and often links treatment to a specific EST. Given that depression accounted for
the vast majority of Marion’s symptoms and negatively impacted Marion’s functioning most,
treatment was planned using a BA framework. Although interpersonal difficulties were apparent
at treatment outset, Marion reported little distress in this domain (likely due to her avoidance of
social situations). Marion’s goal for therapy was to improve her self-esteem; she identified aca-
demic and work-related success as integral to achieving this goal.
Kaufman and Baucom 271

At the time of treatment, Marion had a number of responsibilities she was unable to effec-
tively manage. She was failing her courses, having extreme difficulties at work, and socially
isolated, yet she held expectations that she should be succeeding in each of these domains.
When Marion struggled in any of these areas, she withdrew from the behavior entirely (e.g.,
procrastinating for long periods of time, cutting off communication with friends). Her avoid-
ance served as negative reinforcement, temporarily relieving the pressure to perform in these
domains. For example, Marion would spend hours browsing the internet instead of complet-
ing her schoolwork. This avoidance was an effective short-term solution but functioned to
maintain and exacerbate problems over the long term. As the semester drew to a close,
Marion’s overall distress increased. She had not turned in any assignments and had minimal
communication with her few friends. Marion’s avoidance and subsequent failure in these
areas also served as evidence for Marion’s belief system that she was incompetent, further
discouraging her from engaging in rewarding activities. In the context of a BA framework,
Marion’s avoidance also decreased her chances of receiving positive reinforcement from
accomplishing tasks (e.g., through a sense of mastery or enjoyment). Instead, Marion became
overwhelmed and engaged in other maladaptive behaviors to soothe herself such as spending
money on trivial items.
Consistent with a BA conceptualization, we hypothesized that avoidance was the chief mecha-
nism promoting and maintaining Marion’s depression. Her life was oriented around escape rather
than around pursuing meaningful or rewarding activities. Marion had withdrawn from social
relationships, had a romantic partner with whom contact was necessarily limited (an online rela-
tionship), and engaged in procrastination of schoolwork. She had few opportunities to experience
positive reinforcement for her behavior though pleasure or mastery and was therefore experienc-
ing feelings of low self-esteem.
By mid-treatment, Marion’s depressive symptoms had reduced with successful implemen-
tation of BA (described below). Her time management skills had improved dramatically, which
relieved a significant portion of Marion’s day-to-day stress and positively impacted her school-
work. However, measures of her overall self-esteem (her central treatment goal) were not
showing the expected improvement. This was surprising and indicated the necessity for a shift
in the case conceptualization. As treating Marion’s depression was minimally effective at
increasing her global self-esteem, the hypothesized mechanisms from her problem list were
re-examined. Marion more frequently engaged in enjoyable activities and had reduced the
amount of time spent on less rewarding tasks (e.g., browsing the Internet). However, she was
still spending the vast majority of her time alone or with her immediate family. In discussions
about this, Marion asserted she preferred solitude but simultaneously felt guilty for allowing
her friendships to deteriorate. Reconciling these two pieces of information was important for the
case conceptualization.
Assessment for SAD revealed Marion had always felt out of place around others, even those
she considered close friends. She reported extreme discomfort interacting with individuals in
positions of authority (e.g., professors), speaking in front of others, and talking about herself in
conversation. Her pursuit of solitude was re-evaluated and hypothesized to function as a means
of avoiding social situations. The therapist proposed a new hypothesis to Marion, suggesting her
perceived social incompetency might be driving her low self-esteem. Instead of Marion’s depres-
sion demotivating her from engaging in social activities (as was hypothesized at the start of treat-
ment), perhaps social anxiety was exacerbating or even underlying some of her depressive
symptoms. Initially, Marion contested this theory. However, she agreed with the conceptualiza-
tion after “testing” this hypothesis through some brief exposure work. Marion found that even
contacting friends with whom she felt closest was extremely anxiety provoking. For the remain-
der of treatment, it was hypothesized that her SAD strengthened her social withdrawal and con-
tributed significantly to her low self-esteem.
272 Clinical Case Studies 13(3)

7 Course of Treatment and Assessment of Progress

Pre-Treatment
Marion met with her therapist for two pre-treatment assessment sessions. These appointments
served to orient Marion to CBT, enable Marion and her therapist to collaborate on an initial case
formulation and treatment plan, and gain a firm commitment to therapy. During these sessions,
Marion composed a comprehensive problem list and identified improving self-esteem as her
most important goal for treatment. Her problems in this domain were evident through her poor
body image, her focus on academic and financial failure, and her self-deprecating thought pat-
terns (e.g., “I’m an idiot,” “I am a bad person”).

Sessions 1 Through 6
Marion’s initial treatment sessions were dedicated to understanding and applying the BA frame-
work to her presenting problems. The therapist explained that treatment would begin by observ-
ing the link between Marion’s activities and her mood. Marion was given a copy of a BA
monitoring form where she could track her activity, pleasure, and mastery ratings (on a 1-10
scale), and her emotions hour by hour throughout the day. To understand how Marion was spend-
ing her time, she completed these forms during all waking hours for the first week of treatment.
This exercise revealed that Marion was spending a significant amount of time each day engaging
in unfulfilling activities, and very little time engaging in schoolwork, resulting in feelings of
being overwhelmed, stressed, and disappointed. Marion was surprised to discover that she felt
proud of herself during short periods of time when she worked on homework.
To identify concrete goals, time was spent assessing what Marion thought her life would look
like if she had high self-esteem. She described a more active life where she would complete
schoolwork, see her friends, clean her room, and effectively manage her time. Marion was
encouraged to continue recording her daily activities, along with corresponding ratings of plea-
sure and mastery. She and her therapist worked to schedule rewarding activities such as working
on homework assignments for 30-min chunks of time and spending brief periods of time with
specific friends.
Marion’s compliance with agreed-upon scheduled activities was generally quite good.
Functional analyses were performed to identify obstacles on occasions when Marion was unable
to reach her goals and procrastination was identified as a major obstacle to Marion’s compliance.
For example, Marion would avoid beginning homework assignments at the time she had sched-
uled to work on them. After her planned homework time passed, Marion would become discour-
aged and have thoughts that she missed her opportunity to complete the assignment and should
just give up. Solution-oriented strategies (e.g., use of an alarm to remind her of scheduled activi-
ties, identification of a back-up plan) and cognitive restructuring were used to combat this
problem.
Despite the behavioral focus of treatment, there were a number of sessions during which we
targeted dysfunctional cognitions. Downward arrow (Burns, 1980) was applied to identify under-
lying schemas. Much of the time we identified Marion’s underlying schema as “I am a complete
failure.” Her therapist then asked Marion to challenge this thought with evidence that she was not
a complete failure and together they generated a substantial list of ways in which she was suc-
cessful. Marion kept a record linking her negative thoughts to her mood.
Marion’s depression scores declined (see Figure 1) and Marion achieved several of her goals
by the mid-treatment (e.g., developing good time management skills, catching up on school-
work), but her self-esteem had changed little. Given the original case conceptualization was
formed around the hypothesis that Marion’s depression was causing her low self-esteem, these
data indicated a shift in treatment focus was necessary.
Kaufman and Baucom 273

Figure 1.  Treatment progress (BDI-II and RSES scores).

Note. BDI = Beck Depression Inventory-II; RSES = Rosenberg Self-Esteem Scale.

Sessions 7 and 8
By this time in the course of therapy, improvements were expected in Marion’s global self-
esteem if the underlying mechanism was indeed depression. Marion’s therapist began to explore
potential explanations for improved depression scores but relatively unchanged self-esteem.
When examining Marion’s BA homework assignments, a subtle pattern became evident. The
occasions when Marion was least compliant with her homework typically involved direct social
interactions. Marion could easily text message friends, yet avoided calling or meeting them in
person. This subtlety had been obscured in part due to Marion’s success in other areas, specifi-
cally meeting her work and school-related goals, which were at the top of her goal list. She also
demonstrated an improved ability to reach out to friends via text messaging, email, and social
media.
Once this pattern of avoiding direct social contact had been identified, further assessment of
potential social anxiety was indicated. During Session 7, Marion completed the SIAS and dis-
cussed potential barriers to completing relationship-oriented activities. The MINI section for
social anxiety was completed during Session 8 and confirmed SAD. The therapist discussed a
shift in the case conceptualization with Marion surrounding SAD and its potential relation to her
self-esteem (described above). After some psychoeducation, a SAD diagnosis resonated with
Marion. The therapist and Marion discussed the possibility that she may be avoiding social situ-
ations in part due to the extreme discomfort they cause, even though she had previously attrib-
uted her avoidance to fatigue, poor self-esteem, and a preference for being alone. Marion was
asked to examine her values and her behaviors to determine if SAD was causing her enough
problems to warrant making it a treatment target.
274 Clinical Case Studies 13(3)

Sessions 9 Through 12
By the start of Session 9, Marion had reflected on SAD and its impact on her life. She ultimately
decided her anxiety in social situations had contributed to a number of aversive consequences
with friends and in school. Her fear of speaking in class negatively impacted her grades. Her
unwillingness to engage with her friends caused those relationships to atrophy. She described a
desire for friendships where she could trust others and not fear negative evaluation, but saw that
as impossible. Marion blamed herself for her failed friendships and revealed she “always felt on
the outs.” She described feeling caught between desiring intimacy and realizing she may not be
willing to put in the necessary effort. Marion stated she would ideally make time to spend with
friends, but was unsure that was realistic given her dedication to schoolwork. It is likely that
Marion developed her avoidant patterns after experiencing social rejection. These patterns were
so ingrained by the time Marion sought treatment it was difficult to identify the causal factor (i.e.,
SAD, MDD, or both).
Marion was also very hesitant to begin the indicated exposure-based treatment, stating she
was unsure if she could cope with the strain it would induce. Several sessions were devoted to
psychoeducation and rationale for exposure. The therapist attempted on several occasions to
elicit a commitment from Marion regarding whether she wanted to proceed with this course of
treatment or target a different problem. Often, Marion would commit to confronting her SAD
only to present for the next session wavering again. She and her therapist constructed a fear hier-
archy, yet Marion did not complete exposure-based homework assignments, even when they
were constructed around her lower level feared situations. Her subjective units of distress (SUDS)
were 95/100 during an in-session role-play in which she talked about herself to her therapist,
suggesting Marion’s SAD was debilitating and pervasive.
It wasn’t until the final treatment session (Session 12) that Marion expressed a strong commit-
ment to exposure-based treatment. She completed a homework assignment of calling a good
friend and was surprised at how anxious she felt during their 2-min interaction. She decided that
although exposures caused her significant distress, she needed to work through them. Given the
12-session limit for individual counseling at the clinic where Marion was seen, she was referred
to a group-based workshop on anxiety disorders to continue addressing SAD.

Progress Monitoring During Treatment

Marion’s progress in therapy was regularly assessed using self-report questionnaires. The BDI-II
was used as a primary depression outcome measure and thus was administered prior to every
weekly session. The RSES was administered seven times during treatment to track changes in
Marion’s self-esteem. See Figure 1 for BDI-II and RSES trajectories over the course of therapy.
Marion’s perception of the therapist−client relationship was also assessed three times during
treatment with the WAI-SR; her scores were generally high on this measure (ranging from 73 to
76 out of a possible 84).

Outcome Evaluation
Despite an attenuated SAD treatment response, Marion’s therapy was successful in a number of
ways. Marion’s BDI-II score decreased by 41% (12 points) from pre-treatment to termination,
with her final score (composite = 17) in the mild clinical range of depression. We calculated
Jacobson and Truax’s (1991) reliable change index (RCI) for Marion’s BDI-II from pre-treatment
to termination using Sprinkle et al.’s (2002) test−retest reliability of .96 and their maximum
reported SD of 10.43 among students at UCCs. Marion’s BDI-II RCI was 4.07, suggesting that
her change in BDI-II score indicated reliable improvement in symptoms of depression (i.e.,
Kaufman and Baucom 275

greater than the RCI of 1.96 we would expect based on chance). Similarly, Marion’s reported
self-esteem scores increased by 50% (seven points) from Session 1 to termination, although her
final RSES score (composite = 21) was still approximately two standard deviations below the
college student mean. Based on Blascovich and Tomaka’s (1993) test−retest reliability of .82 and
Schmitt and Allik’s (2005) reported SD of 5.01, Marion’s RSES RCI was 2.33, suggesting that
she did evidence a reliable increase in self-esteem over the course of treatment despite remaining
below college student norms. She was on track to passing all of her classes and had gained skills
for better time management. Overall, Marion’s functioning improved with successful implemen-
tation of BA despite failing to identify her comorbid SAD until well into treatment.

8 Complicating Factors
There were several complicating factors affecting the treatment and outcome of this case. First,
the diagnostic overshadowing of SAD by MDD resulted in the delayed implementation of poten-
tially effective treatment approaches. Had exposure-based interventions been used throughout
the course of treatment, Marion may have experienced more substantial gains. This diagnostic
overshadowing likely occurred for several reasons. First, Marion frequently described and attrib-
uted problems that were ultimately conceptualized as resulting from SAD to symptoms of MDD
(e.g., fatigue) or a personal preference for solitude. The terms “anxiety,” “fear,” and “nervous-
ness” did not resonate with Marion until her therapist applied them to situations Marion had
previously discussed in sessions. For example, Marion described being uncomfortable interact-
ing with clients in her work environment. When Marion’s discomfort was further assessed, she
framed her concerns in terms of feeling worthless, guilty, and incapable rather than fear of social
evaluation. As previously described, Marion also had a tendency to minimize her anxiety symp-
toms. However, when asked to engage in a socially oriented role-play in session, the debilitating
nature of her SAD became more salient. Only after time in therapy and the therapist’s exposure
of Marion to feared situations was a SAD diagnosis uncovered. A final contributor to the diag-
nostic overshadowing was the lack of a structured diagnostic assessment at the initiation of
treatment.
Another obstacle to treatment was Marion’s initial resistance to engaging in exposure therapy
for SAD. The therapist was unable to elicit a strong commitment to this treatment strategy until
the final session, leaving no time to implement this approach during a time-limited course of
therapy. Had the SAD–MDD comorbidity been identified at the outset of therapy, a more inte-
grated approach with an exposure component may have been utilized effectively. A third compli-
cating factor was Marion’s agreeable nature. She agreed to most interventions proposed and most
observations made by her therapist. At times, this hindered progress. On several occasions
Marion agreed to homework assignments that, on later discussion, she identified as too difficult.
Unfortunately the lack of completion of these assignments served as additional support for her
negative beliefs about herself. In addition, although Marion verbally agreed with the therapist’s
case conceptualization, at times it was unclear if she fully understood and agreed with the ratio-
nale for interventions and the overall treatment plan. Her therapist raised concerns about Marion’s
agreeable tendencies in the context of sessions, but in hindsight this could have been challenged
more effectively (e.g., role-playing exercises where Marion was instructed to disagree with her
therapist, cognitive restructuring, etc.).
A final obstacle was Marion’s clipped response style. She was not particularly talkative or
generative with session content and struggled to elaborate on her comments when prompted. This
barrier was likely related to Marion’s SAD, and caused problems even within the context of an
effective therapeutic relationship (see Marion’s WAI-SR scores). At times, her response style
resulted in communication difficulties, contributing to her therapist’s solution-focused, directive
approach.
276 Clinical Case Studies 13(3)

9 Access and Barriers to Care

Marion was seen in the context of a UCC where students and staff pay out of pocket on a sliding
fee scale. The clinic where Marion was seen used a 12-session limit on individual therapy per
client per calendar year. This restriction, in combination with the aforementioned complicating
factors, made effectively addressing all of Marion’s presenting complaints unrealistic. Fortunately
we were able to refer her to group treatment focused on anxiety-related symptoms.

10 Follow-Up
Post-termination assessment was not possible with Marion due to treatment setting restrictions.

11 Treatment Implications of the Case

The data from this case elucidate the difficulties in identifying diagnostic overshadowing and
addressing problems on which the client is not fully invested in working. Marion presented to
treatment wanting to improve her feelings of self-esteem. Despite being asked, Marion denied
anxiety regarding her social relationships until well into the course of therapy, making it easy to
overlook the presence and significance of her SAD. Perhaps if a structured interview such as the
MINI screener (Sheehan et al., 1998) followed by indicated sections of the MINI had been
administered at the start of treatment, SAD would have been more readily identified. Once iden-
tified, it took several sessions to establish if Marion was willing to engage in the ideal treatment
to target her anxiety (exposure-based methods, which caused acute discomfort). By the time she
had committed to the treatment plan, clinic restrictions (a 12-session limit) prohibited execution
of exposure-based interventions within the context of individual therapy.
Interestingly, exposure and BA share common elements (e.g., re-engagement in avoided
behaviors, tracking emotional response to executing these behaviors). Given these key areas of
overlap, it may be considered surprising that Marion’s social anxiety did not substantially
improve dramatically with successful implementation of BA. From an exposure-based frame-
work, her avoidance kept her from facing her discomfort and accumulating evidence that she
could endure it. Both Marion’s BA schedule and her planned exposures involved re-connecting
with friends she had previously lost contact with. However, when working within a BA frame-
work prior to identification of comorbid social anxiety, Marion was spending the majority of her
time re-engaging in schoolwork. If social experiences had been a greater focus during BA, greater
improvement in social anxiety scores would be likely. Future research should examine whether
BA focused on social engagement is effective at reducing social anxiety, or whether a traditional
systematic desensitization exposure-based framework provides unique benefits.

12 Recommendations to Clinicians and Students

It is important to take comorbid diagnoses into account when treating Axis I disorders. Recent
studies demonstrate that comorbid mood disorders often negatively impact the efficacy of cogni-
tive behavior therapy (CBT) for SAD (e.g., Erwin, Heimberg, Juster, & Mindlin, 2002). Clients
with this pattern of comorbidity have less favorable treatment outcomes compared with those
with MDD and a different co-occurring anxiety disorder, as well as those with MDD or SAD
alone (Campbell-Sills et al., 2012; O’Neil & Kendall, 2012). Similarly, another study found those
with SAD–MDD had higher depression scores at baseline and throughout the course of treatment
(Joormann, Kosfelder, & Schulte, 2005). Even the presence of subclinical depressive symptoms
has a detrimental impact on the treatment of SAD. These symptoms were related to more severe
SAD, less improvement in social anxiety symptoms over time, and non-response to treatment
Kaufman and Baucom 277

(Ledley et al., 2005). Some studies have found that although MDD at the onset of treatment did
not predict poorer treatment response, it predicted exacerbation of SAD symptoms following
treatment termination (Marom, Gilboa-Schechtman, Aderka, Weizman, & Hermesh, 2009).
Identification of comorbid Axis 1 disorders requires careful assessment at the outset of treat-
ment in the form of a structured interview and regular monitoring of progress throughout treat-
ment. Lengthy diagnostic interviews (e.g., SCID) are not always possible depending on the
treatment setting, staff expertise, and resources. However, even when a full interview cannot be
given, treatment providers ought to rule out commonly co-occurring diagnoses on identification
of a primary Axis I disorder. For example, clinicians could ask a few brief items to rule out SAD
and other anxiety disorders when working with MDD clients, and should also be vigilant in iden-
tifying MDD when treating anxiety. Similarly, giving comprehensive measures that are designed
to track a wide range of symptoms week-to-week could bring to light a previously overlooked
diagnosis. Yet diagnostic overshadowing may occur even in cases where a full diagnostic assess-
ment and careful monitoring are in place. Marion attributed her symptoms of SAD to depression,
and may have denied items designed to assess for SAD at the start of treatment. A data-driven
case-conceptualization and careful monitoring of her homework assignments were helpful tools
for identifying her comborbidity.
As no formal treatments have been developed for an SAD–MDD comborbity specifically, we
must draw from existing evidence-based approaches in the treatment of these high-risk clients.
As described above, there are some striking similarities between exposure-based approaches and
BA. Integrating these treatments may be particularly helpful when treating those with an SAD–
MDD comorbidity. Using activity scheduling and monitoring to target and increase social activi-
ties may function as exposure for these clients. Pairing this activity scheduling with in-session
gradual exposure techniques to feared situations could add incremental benefit to treatment.
Future studies should examine the utility of this strategy.
Three other treatment approaches have potential for successfully treating SAD–MDD comor-
bidity. First, Barlow, Allen, and Choate (2004) developed a Unified Protocol for the Treatment of
Emotional Disorders for transdiagnotic care, which may be promising. This approach is based on
three fundamental components of effective therapy targeting emotional disorders, one of which
is preventing emotional avoidance. This approach provokes emotional expression through vari-
ous exposure techniques (e.g., in vivo, interoceptive, imaginal, etc.) and through standard mood-
induction exercises. These procedures differ from client to client only in the situational cues and
chosen exercises, yet the mechanisms are hypothesized to be largely the same.
Second, Acceptance and Commitment Therapy (ACT; Hayes, Strosahl, & Wilson, 1999) is
another promising approach to treating a SAD–MDD comorbidity (Craske, 2012). From this
approach, psychopathology arises from an unwillingness to experience uncomfortable thoughts
and emotions. Clients engage in experiential avoidance in an attempt to control or eliminate these
unpleasant experiences. Unfortunately, attempts to avoid these thoughts and feelings actually
increase their frequency and intensity, causing further problems. ACT aims to increase clients’
psychological flexibility to better accept and cope with unpleasant experiences. Recent research
has demonstrated ACT’s effectiveness for co-occurring anxiety disorders and depression (Arch
et al., 2012). Dalrymple (2012) suggests that ACT may be particularly effective for those with
SAD–MDD diagnoses because it may facilitate client engagement in behavioral activities that
are meaningful and value driven. While BA targets an increase in pleasant activities, ACT
engages clients in exploration of their deeply held personal values. Finally, mindfulness exercises
may increase clients’ ability to engage in value-driven behaviors they previously avoided due to
associated thoughts and emotions.
Marion’s case illustrates the importance of the case conceptualization in identifying diagnos-
tic overshadowing. Persons (2008) emphasizes the importance of continually collecting formal
assessment and informal observational data, and reflecting on how new findings fit within the
278 Clinical Case Studies 13(3)

clinician’s overall understanding of the case. Once certain problems are treated, others may arise,
or become visible to the therapist for the first time. Comorbidities may not be apparent at the
beginning of treatment for various reasons, despite thorough assessment. However, observing
how and when treatment strategies are and are not effective is essential throughout the course of
treatment. In addition, remaining attuned to seemingly small details of the case can prove
extremely important. Although Marion’s anchoring diagnosis of depression was improving as we
expected mid-way through therapy, her poor self-esteem remained. This problem masqueraded
as a symptom of depression; however, the true culprit was SAD. Remaining flexible, updating
the case conceptualization when new information was revealed, and working collaboratively
with Marion enabled the clinician to uncover a second diagnosis and refer Marion appropriately.
All practitioners would benefit from utilizing a data-driven, flexible conceptualization when
treating their clients, especially those with complex presentations.

Acknowledgments
The authors would like to acknowledge the case study participant and the staff of University of Utah’s
counseling center.

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
Erin A. Kaufman, BA, is a student (clinical) in the Department of Psychology at the University of Utah.
She researches the pathogenic processes underlying the development of borderline personality disorder
(BPD). Clinically, she is interested in evidence-based practice and the flexible applications of cognitive-
behavioral treatments, particularly dialectical behavior therapy.
Katherine J. W. Baucom, PhD, is an assistant professor (clinical) in the Department of Psychology at the
University of Utah. She teaches and supervises cognitive behavioral therapy for mood and anxiety disor-
ders. Her research is primarily focused on couple relationships, including the study of basic dyadic pro-
cesses as well as translational applications in treatment outcome research.