The girl, who was in her early teens, barely looked at me, barely spoke to me, and mumbled so quietly I kept leaning forward until I nearly fell out of my chair.
Her mother had brought her for a psychological evaluation, worried that her daughter had been spending most of her time in her room and was no longer initiating contact with peers or seeing them outside of school. She was also more moody, bursting into tears easily and always ready to lash out in anger when she was simply asked to complete her usual chores or spend time with the family.
"Always a bit shy" as a younger child, the girl was withdrawing to a frightening extent. "She talks so quietly," her mother said. "People can't hear her. She doesn't make eye contact."
And when she could make herself understood, "she talks about a different topic than the one under discussion," her mother added.
I was hearing - and observing - some behaviors consistent with Autism Spectrum Disorder. Perhaps this patient, like many mildly autistic girls, had made it through grade school without anyone noticing that her "shyness" was masking subtle deficits in accurately interpreting others' intentions, beliefs, and emotions. These autistic deficits often become glaring around the tween years, when the focus of girls' friendships shifts from playing games to sharing thoughts and feelings.
But a more likely diagnosis, given her misery and irritability - not to mention her gender and age - was depression. Relatively infrequent in children, depression rises sharply among teenagers, particularly girls, who are nearly three times as prone to it as boys. Teens who are depressed frequently withdraw from pleasurable activities of life, including socializing with friends and family. And, indeed, our diagnostic interview did reveal she had severe depression.
But just how socially uncomfortable she was - even in the presence of a therapist offering compassion and help - suggested a more complicated picture.
Further interviewing resulted in a diagnosis of social anxiety disorder, which had started around the time the young woman began middle school and which preceded the depression by two years.
People with social anxiety grossly overpredict negative evaluation by others. They typically have age-appropriate social understanding and skills, but are so terrified of doing something embarrassing they begin to change the way they communicate or outright limit social interactions. This is different from the "shy" teen with Autism Spectrum Disorder who may have learned through many painful experiences to accurately predict that she will make social errors and so avoids socializing.
Moreover, social anxiety - and the isolation that accompanies it - makes life so miserable for teens that most will go on to develop depression as a secondary disorder if the anxiety is left untreated.
The fact that the social phobia emerged first in my patient's developmental history informed the treatment plan. We focused first on cognitive-behavioral interventions that directly addressed the social anxiety rather than the depression. Frequently, I find that when the primary anxiety is successfully treated, the secondary depression goes away on its own. But because this patient's depression was so severe, I referred the family to a psychiatrist and the girl began taking an antidepressant.
My patient worked exceptionally hard in her therapy and took her medication faithfully. Within 15 sessions, the change was remarkable. It turned out she is a lovely conversationalist - empathic and socially skilled and funny. I almost hated to graduate her from our weekly therapy . . . but her social calendar was really filling up.
Katherine K. Dahlsgaard is lead psychologist of the Anxiety Behaviors Clinic at Children's Hospital of Philadelphia.