Flashbacks in Social Anxiety Disorder: Psychopathology of a Case
Kummer, Arthur, Harsanyi, Estefania, Indian Journal of Psychiatry
Byline: Arthur. Kummer, Estefania. Harsanyi
Social anxiety disorder is characterized by overwhelming anxiety in everyday situations which are frequently avoided due to a fear of being watched and scrutinized by others or acting in an embarrassing way. Flashbacks are typical symptoms of post-traumatic stress disorder, and their main features are intrusive and vivid images that occur in a waking state. We present a case study of a man diagnosed with social anxiety disorder who had reexperiencing symptoms similar to flashbacks of what he considered "shameful situations". The differential aspects between flashbacks and obsessional imagery are discussed. Reexperiencing symptoms and imagery of social phobia as well as the sociocultural influence over the symptomatology of psychiatric disorders are then highlighted.
Social anxiety disorder, also known as social phobia, is now well recognized as one of the most common psychiatric disorders. With an onset early in life, it is frequently impairing and associated with other anxiety disorders, depression, and substance use disorders.[sup]  Persons who have the generalized type of the disorder, fear or avoid most social situations, while people with the nongeneralized type of the disorder report anxiety or avoidance to limited performance situations.
Flashbacks are defined as involuntary, recurrent, intrusive and vivid images of a trauma that emerge in someone's mind in a waking state.[sup]  It is also conceptualized as re-experiencing part of a traumatic event with a realistic intensity as if it were happening in the present. These phenomena are one of the core symptoms of post-traumatic stress disorder (PTSD) and are sensitive and specific indicators of the presence of trauma.[sup] 
Although flashbacks are not pathognomonic of PTSD, these symptoms are only associated to PTSD and to drug-related phenomena. We present a singular case in which a young man with social anxiety disorder presents flashback(s) of what he considered "shameful situations".
Mr. "A" is a single 26-year-old student, who attended our psychiatric unit with a complaint of severe anxiety in some social situations. Starting in his early teens, he noticed extreme anxiety when engaged in public speaking or socially approaching girls. He also reported a milder discomfort when talking to strangers and people in authority as well as speaking up in meetings. Despite feeling extremely anxious and fearing that he could act in a way which would embarrass himself, he insisted in enduring most of these situations. However, soon after this, he begins to censure himself for what he considered "shameful situations". Curiously, he described repeated and distressing recollections, with realistic intensity, of what he considered his "worst moments". He tried unsuccessfully to suppress these vivid images as they emerged involuntarily and intrusively. At these moments, he felt moderate psychological distress and mild physiological reactivity. These specific symptoms progressively waned within a few weeks and were replaced by other scenes of situations that he endured and described as "shameful moments". They were similar to the flashbacks seen in PTSD, apart from the fact that Mr. A's description had an observer's perspective (i.e., seeing himself as if through the eyes of another person).
He received a diagnosis of social anxiety disorder according to DSM-IV criteria and engaged sessions of cognitive psychotherapy focusing on social anxiety disorder. Considering these flashbacks were fed by negative automatic thoughts related to social phobia, we expected that they would concomitantly ameliorate. The treatment aimed mainly at correcting dysfunctional negative self-appraisals and beliefs, and shifting the direction of his attention to the external aspects of the social environment, instead of his internal processes when undergoing the feared situations. …