Case Formulation

1
Case Formulation

• Source Page A. C. Stritzke W. G. K. (2006).
  Clinical psychology for trainees Foundations of
  science-informed practice. Cambridge Cambridge
  University Press.

2
A Referral

• Please consider Ashley a 23 year old male with
  atypical Social Anxiety Disorder. He has not
  responded to a course of propanalol (Inderal a
  Beta blocker that has been used to treat social
  anxiety) and so a trial of Cognitive-Behaviour
  Therapy at the Robin Winkler Clinic may prove
  beneficial.

3
Interview

• An initial assessment found Ashley to be a
  personable man who worked as a clerk in a law
  firm since completing high school. He reported
  no psychopathology except for a particular
  symptom he would vomit at inappropriate times.
  Specifically he would vomit when becoming
  intimate with females. A typical occurrence
  would be that he would contact a friend at work
  during the day and arrange a liaison in a
  deserted office. Upon arrival they would start
  to become intimate and he would become sexually
  aroused at which point he would begin to feel
  nauseous. He would then excuse himself
  commenting that he needed to put a condom on
  vomit brush his teeth and return to the
  rendezvous. He noted that he did not feel
  worried about his performance just annoyed that
  he had to interrupt an otherwise pleasurable
  experience in order to vomit. When the amorous
  encounter was over they would return to work.
  Although his present partner found his behaviour
  puzzling Ashley had not explained his difficulty
  to his partner. The problem had caused the break
  up of many past relationships and Ashley was keen
  to find a way to minimise this occurrence of
  vomiting and he was worried that if he did not
  resolve the problem quickly his current partner
  would leave him if she found out.

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Definition

• hypothesis about the causes precipitants and
  maintaining influences of a persons
  psychological interpersonal and behavioral
  problems. A case formulation helps organize
  often complex and contradictory information about
  a person. It should serve as a blueprint guiding
  treatment as a marker for change as a structure
  for enabling the therapist to understand the
  patient better. A case formulation should also
  help the therapist anticipate therapy-interfering
  behaviors and experience greater empathy for the
  patient broadly a psychotherapy case
  formulation also includes descriptive information
  on which the hypothesis is based and prescriptive
  recommendations that flow from the hypothesis
• (Eells 1997 p. 2 italics in original).

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(No Transcript)
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Cognitive Behavioural Case Formulation

• Persons (1989 1993 Persons Tompkins 1997)
• Extension includes an assessment of cognitive
  beliefs and attitudes (see J. Beck 1995
  Freeman 1992 Muran Segal 1992 Turkat
  Maisto 1985 for other examples).

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Development of Case Formulation Skills
(3.01)
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Problem List

• Comprehensive descriptive concrete list of the
  presenting problem(s) and any other difficulties
  that the client may have. (analogous to the
  Behaviour of the ABC)

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Core Beliefs

• Set of hypotheses about the cognitions or beliefs
  that could explain the origins or the maintenance
  of some or all the problems in the problem list.

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Precipitants and Activating Situations

• Precipitants are analogous to the Antecedents
  within the ABC model of the functional analysis
• Activating situations are also antecedents but
  refer to those that explain the problem more
  generally and explain the consistency across
  situations.

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Working Hypothesis

• Unlike the functional analytic approach Persons
  and Tompkins make no explicit statement about
  consequences of a given behaviour.
• Instead clinician develops a theory that links
  the problems on the problem list the core
  beliefs and the activating events and situations.

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Origins

• Outlines early events that may explain the origin
  of core beliefs. E.g. predisposing variables
  such as early experiences of parental loss that
  may set stage for pathology by creating
  expectations of abandonment or hopelessness.

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Treatment Plan

• not a component of a case formulation but they
  suggest that since a treatment plan will flow
  from the working hypothesis it is an aid to good
  clinical practice to get into the habit of
  including the plan along side the hypothesis.

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Predicted Obstacles to Treatment

• Finally the psychologist is encouraged to
  explicitly use the problem list core beliefs
  and working hypothesis to identify predicted
  obstacles to treatment.
• These may refer to potential difficulties in the
  therapeutic relationship compliance with
  treatment strategies abilities understanding
  psychoeducation or interpretations of the
  problems recruiting motivation and so on.
• The psychologist can then identify ways to
  address these obstacles.

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Analysis

• The strengths of Persons approach is that the
  mediational role of core beliefs is identified
  the treatment plan and obstacles to its
  implementation are linked to the formulation.
• The chief weaknesses are that it fails to
  explicitly include the Consequences identified
  in a functional analysis and the origins are
  mentioned but not fully integrated into the
  working hypothesis.
• Finally while the sequence (beginning with the
  problem list) might match the order in which
  clients present information the sequence does
  not follow a theoretical order of problem
  development.

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Page Stritzke (2006)The Seven Ps

• Thus our preference is to use the headings of
• (i) Presenting Problems
• (ii) Predisposing factors
• (iii) Precipitating variables
• (iv) Perpetuating cognitions and consequences
• (v) Provisional conceptualization
• (vi) Prescribed interventions and
• (vii) Potential problems and client strengths.

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Cognitive Behavioural Case Formulation Worksheet

• Presenting Problems
• 1. 2.
• 3. 4.
• 5. 6.
• 7. 8.
• Predisposing factors
• 1. 2.
• 3. 4.
• Precipitating variables
• 1. 2.
• 3. 4.
• Perpetuating cognitions and consequences
• Cognitions Behavioural Consequences
• Problem conceptualization
• Prescribed interventions
• 1. 2.

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Presenting Problems

• Psychologist Whats brought you here today
• Client Ive been suffocating all of a sudden
  for no reason. My doctor tells me theres
  nothing wrong but shes never done a test when
  its happening.
• P Whats it like when you start suffocating
• C Well I can be sort of normal one minute and
  then bang its like the panic button gets pushed
  and Ive just got to get out of there to get some
  air. I start to choke and my throat closes over
  like Im going to suffocate. If I dont get some
  air Im sure Ill pass out die or something
  like that.
• P This lack of air is so great its as if you
  are going to die.
• C Thats right. No-one seems to understand and
  they all say that Im not going to suffocate
  that there is plenty of air that my lungs are
  OK but it doesnt help. I know theres plenty
  of air but no-one seems to understand that the
  air isnt getting where it should. I dont need
  anyone to tell me that these problems are in my
  head. I can feel these sensations in my body.
  My heart pounds I feel dizzy my legs go to
  jelly. I even get tingling in my hands. Try to
  tell me thats not a sign of suffocation!
• P Its a pretty serious problem to have all
  these signs of suffocation. Id be quite worried
  if I started suffocating out of the blue.
• C Out of the blue thats how it is. Ill be
  walking along one minute and then my body just
  packs up and theres no air.

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Precipitating variables

• P Thanks for telling me about how you feel
  during one of the suffocating episodes. If its
  OK with you Id like to talk about what they are
  like and the effect they are having on your life
  but for the time being Id like to concentrate on
  what triggers the suffocation. Could you tell me
  about the most recent time you felt you might
  suffocate
• C I was out to dinner with some friends a hens
  night actually. I was a bit worried that I might
  not feel well and have to leave. Since it was
  Claires hens night I felt that I really
  couldnt walk out one her so I was extra
  worried. Before I got to the restaurant I got
  hot and flustered because I couldnt find a
  parking spot. I was driving round and around
  thinking If I dont get a spot quickly then
  Ill be late and all the seats near the door will
  be gone.
• P And if they were all gone
• C I wouldnt be able to get out for some air
  without everyone noticing. And thats just what
  happened. I walk in all hot and bothered only to
  find that the only seat left is the one at the
  end of the table right down the back of the
  restaurant.
• P So what did you do
• C I just felt like leaving right then and there
  but I didnt. I took a couple of deep big
  breaths and took my seat. The moment I sat down
  I knew it was all over. My throat tightened up
  and my chest started to hurt. I started to
  breathe faster to get some air but the air in
  the restaurant was too hot. It wouldnt get into
  my lungs no matter how hard I breathed perhaps
  it was the spices in the cooking but whatever
  it was I knew I just had to get out.

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Precipitating variables (Cont.)

• P What if you didnt get out
• C Id probably pass out or die. I dont know
  exactly because I gave some excuse about having
  forgotten to put some money in the parking meter
  and I left. Just like that. I got up walked
  out and never went back.
• P Have you always had these episodes of
  suffocation
• C When I was young I used to have asthma
  attacks but theyve stopped. Anyway the asthma
  attacks were different. I cant really describe
  it is words but I know an asthma attack and
  these feelings of suffocation are different.
  Theyre not wheezy like asthma.
• P After the asthma attacks stopped was there a
  time before these episodes of suffocation began
• C Yes the asthma stopped in my teens and the
  suffocation didnt start until my mid 20s.
• P Was there anything going on around the time
  they started
• C It was a pretty horrible time in my life.
  Things were pretty stressed at work. There were
  lots of people being made redundant and there was
  a new round of redundancies in the wind. I went
  to a party and everyone was smoking dope. I
  hadnt smoked before because of my asthma but I
  figured that since it was gone I deserved a bit
  of relaxation. The first few puffs were OK but
  then I started to feel short of breath my throat
  started to close up and I started to think I was
  having an asthma attack. I stopped smoking and
  ran outside to get some fresh air.

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Perpetuating cognitions and consequences

• P You have told me about a lot of things that
  seemed to trigger these sensations of
  suffocation but I wonder if you could tell me
  more about what you were thinking. What is the
  last thought you remember before the feelings of
  suffocation were at their worst
• C When they were at their worst I dont think I
  was thinking anything. I just go blank.
• P What was the last thought you remember before
  going blank
• C I thought Ive just got to get out
• P Why did you need to get out
• C I needed fresh air. Ive found that when Im
  suffocating getting out and into the fresh air
  sometimes helps.
• P What if you hadnt been able to get out
• C That was what I was worried about. I was sure
  that I was going to run out of air. The
  restaurant was full of people the door was
  closed and there was an open fire in the kitchen
  out the back.
• P An open fire
• C You know a BBQ type of thing where they were
  cooking the steaks. I could see the flames
  coming up and I know that flames use oxygen to
  burn.
• P So the fire was using up the oxygen in the
  room
• C And because the door was closed and the
  restaurant was full the oxygen was getting used
  up. If I had been able to sit closer to the door
  I might have been able to get more oxygen but
  being close to the kitchen meant that I had less
  oxygen.

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Perpetuating cognitions and consequences (Cont.)

• P Had anyone else noticed the lack of oxygen
• C No. I think Ive got some sort of allergy
  that makes me sensitive to the absence of air.
  Ive read about this disease called Undines
  Curse where babies die because they arent
  sensitive to oxygen or carbon dioxide or
  something so they dont breathe enough. Ive
  worried I might have that but all the doctors
  say my heart and lungs are fine.
• P Does their reassurance help
• C For a while but once the suffocation comes
  back again I think What do they know. If they
  had done their tests while I was suffocating the
  readings would be different.
• P You cant remember what you were thinking when
  the feelings of suffocation were at their worst
  but do you remember how you were feeling
• C Really panicky freaked out. My heart was
  beating so fast and I was really scared I was
  going to die.
• P And then what happened to these feelings when
  you left
• C Once I got out into the cool air they melted
  away. I walked away from the restaurant and
  after a few minutes of letting myself breathe the
  rich air I started to feel the oxygen flooding
  through me. I didnt have to breathe so quickly
  and I knew that I was going to be OK. Well sort
  of OK.
• P Sort of OK
• C Well I wasnt going to suffocate but then I
  started to think about my friends. They would
  all be sitting there waiting for me to come back
  but there was no way I was going back. By the
  time I got back to the car I had tears running
  down my face. They were tears of relief that I
  had got out alive as well as tears of shame that
  I couldnt even sit in a restaurant without
  leaving. Why cant I be normal

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Predisposing factors

• P You have described some pretty terrifying
  experiences all of which seem to involve intense
  feelings of suffocation. Feeling you are about
  to suffocate leads you to do the only sensible
  thing which is to get out and get to a place
  where there is more air. I wonder if you have
  thought about where this all has come from
• C I dont really know but my mother was pretty
  highly strung and worried about everything. When
  I was a child she worried a lot about my asthma.
  There were certainly lots of kids at school who
  were worse than me but she kept insisting that
  we went to the doctor or casualty to get me
  checked out. It seemed to make her feel better
  when they said I was OK.
• P Hows you asthma now
• C The doctors say they cant find a trace of it
  but sometimes I think Ive taken on the role of
  my mother looking after my health.
• P You described your mother as highly strung.
  Are you like you mother in this respect
• C Ive always been a nervous person. Ive
  worried about my health for as long as I can
  remember.

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Provisional conceptualization

• In this instance the psychologist suggested that
  the clients personality was likely to reveal
  elevations on neuroticism which would set the
  stage for the development of an anxiety disorder.
• The experience of management of asthma attacks
  provided a template for health behaviour that
  involved worry about symptoms and escape and
  reassurance seeking as ways to reduce the
  distress associated with possible illnesses.
• Against this backdrop each individual attack
  began with awareness of a particular bodily
  sensation or set of sensations (e.g. shortness
  of breath). These sensations were misinterpreted
  as signals of impending danger which in turn
  triggered the anxiety (or fight or flight)
  response.
• Increased respiration a normal part of the
  anxiety response led to hyperventilation in the
  absence of either flight or fighting which in
  turn produced more sensations.
• Together these sensations would be
  misinterpreted as signals for suffocation and so
  on in a vicious circle of panic.
• The spiral would be ultimately broken by flight
  which would involve action

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Clarks Cognitive Model of Panic
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Testing the Formulation

• This can be done by presenting the formulation to
  the client in a formal manner and asking for
  feedback as to its ability to consolidate the
  clients problems.
• Test aspects of the formulation (see Turkat
  Maisto 1985 for some examples) with psychometric
  tests. With the client in question a personality
  inventory (the NEO-PI-R Costa McCrae 1992)
  was administered to determine if the trait
  anxiety was elevated.
• The SCL-90-R was also administered to provide a
  standardized broad pre-treatment assessment that
  could be used to evaluate changes during and
  post-treatment. The results of testing are
  displayed.

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Assessment Profiles
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Testing the Formulation

• The scores for the personality dimension of
  Neuroticism (N) are very high consistent with
  the expectations however interestingly
  conscientiousness (C) is very low.
• The low conscientiousness was not a theme that
  had emerged during the interview and suggested an
  area that required further investigation
  particularly as it might indicate a problem for
  compliance with treatment.
• Extraversion (E) Openness (O) and Agreeableness
  were average.
• The SCL-90-R showed elevations on somatization
  anxiety and phobia which were all consistent
  with the reports of panic attacks.
• In addition the elevation on the
  obsessive-compulsive interpersonal sensitivity
  and depression dimensions all suggested the
  existence of symptoms that have not been
  discussed in the sections reproduced. This
  highlights one advantage of using broad symptom
  measures at the outset of treatment in that they
  can identify areas of symptomatology that may
  have been ignored in the initial assessment
  interview(s).

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Prescribed interventions

• The empirically-validated interventions for panic
  disorder and agoraphobia have been clearly
  documented in many difference sources (Andrews
  et al. 2003 Barlow 2001 Clark Salkovskis
  1996 Taylor 2000).
• Each important component of the model will be
  addressed with a particular treatment and the
  rationale for each component can be demonstrated
  to the client with reference to the formulation.
  Importantly the cognitive behavioural package
  that involves these components has been
  empirically-validated in a variety of studies
  lending further support to the use of these
  techniques (see Clum Clum Surls 1993 Cox
  Endler Lee Swinson 1992 Gould Otto
  Pollack 1995 Mattick Andrews Hadzi-Pavlovic
  Christinesen 1990 Taylor 2000). In addition
  there are studies demonstrating the individual
  efficacy of each component (Ito de Araujo Tess
  de Barros-Neto Asbahr Marks 2001 Salkovskis
  Clark Hackman A. 1991 Michelson Marchione
  Greenwald Testa Marchione 1996 Öst
  Westling 1995 Williams Falbo 1996).

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Linking Formulation to Treatment
31
Potential problems

• Low conscientiousness identified by the NEO-PI-R
  (Costa McCrae 1992) represents a possible
  problem in treatment suggesting that the
  compliance with treatment and homework exercises
  will need to be monitored carefully.
• Presence of worry and anxiety combined with the
  need for exposure to bodily sensations and
  situations associated with anxiety. It is likely
  that the clients motivation and their impatience
  to begin treatment will wane as the threat of
  elevated anxiety and panic looms therefore these
  will need to be monitored and addressed if
  treatment is going to be successful.

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Cognitive Behavioural Case Formulation Worksheet

• Presenting Problems
• 1. Distressing bodily sensations (heart pounding
  dizziness choking shortness of breath and
  tingling in the extremities)
• 2. Fear of suffocation
• Predisposing factors
• 1. 2.
• 3. 4.
• Precipitating variables
• 1. Anticipatory worry 2. Situations where escape
  difficult
• Perpetuating cognitions and consequences
• Cognitions Behavioural Consequences
• Ive just got to get out Flee situation and
  panicky feelings decrease
• Sensations of shortness of breath mean I will
• suffocate and die
• Problem conceptualization
• Prescribed interventions
• 1. Graded exposure 2. Cognitive restructuring
• 3. Interoceptive exposure 4. Breathing control
  relaxation
• Potential problems

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Putting it Altogether
34
Ashley Again

• The main elements in the description revealed
  that Ashley identified this problem as an
  isolated instance of psychopathology it was
  preceded by anticipatory worry then sexual
  arousal and following vomiting the experience
  dissipated and he was able to return to sexual
  activity. Two hypotheses occurred to the
  psychologist.
• First it was possible that the vomiting was a
  consequence of extreme anxiety.

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Scales
36
Ashley (Cont.)

• The second hypothesis was that the vomiting was
  related to a disgust reaction.
• The Disgust Sensitivity Scale (DSS Haidt
  McCauley Rozin 1994) assesses seven domains
  of disgust sensitivity. This scale revealed that
  Ashley was generally elevated on this scale but
  particularly on the items concerning sexual
  practices.
• Consistent with these elevations the interview
  revealed that Ashley experienced a disgust
  reaction which was characterized by flushing
  sweating hot and cold flushes nausea
  gastrointestinal distress and choking. The
  interview then used a functional analytic
  approach to determine the antecedents and
  consequences associated with the disgust.
• It transpired that during one of his first sexual
  encounters Ashley has seen some menstrual blood
  felt disgust and fainted (see Page 1994 2003).
  Since then he worried that he might faint but
  found that if he vomited fainting did not occur
  and his feelings of disgust were alleviated. The
  antecedents (e.g. underwear) of the behaviour
  (i.e. the disgust reaction) were identified and
  the response (i.e. avoidance to vomit to obtain
  relief).