Home > Case Studies Solutions > Adult Psychological Assessment Cases

Adult Psychological Assessment Cases

558 views

Case 1

Case Summary

Y.N. was a 27 years old lawyer who had completed his LLM and belonged to an upper middle socio-economic class. He came to the Center for Clinical Psychology with the complaints of excessive worrying and concern about his own health, family’s well being, business and future. The worrying was accompanied by headache, fatigue, restlessness and disturbance in personal and social life. He was assessed through a clinical and diagnostic interview, mental status examination, GADS-7, Metacognitions Questionnaire and DSM-5 checklist. The client was diagnosed with Generalized Anxiety Disorder and the management of his symptoms was done according to the techniques of Cognitive Behavior Therapy. The techniques used during his management were psycho-education, guided questioning, suppression experiments, questioning the evidence and mechanism of negatively associated meta-beliefs, dissonance techniques and relaxation exercises. The comparison between pre and post assessment revealed improvement in the client’s symptoms and his overall functioning.

Bio-Data

Name: Y.N.

Age: 27 years

Gender: Male

Education: Currently enrolled in LL.M

No. of Siblings: 3

Birth order: Last born

Marital Status: Single

Occupation: Lawyer

Religion: Islam

Informant: Client Himself

Reason and Source of Referral

The client came to Centre for Clinical Psychology with the complaints of excessive worrying and concern about his own health, family’s wellbeing, business and future. The worrying was accompanied by headache, fatigue, restlessness and disturbance in personal and social life. He was referred to the trainee clinical psychologist for the assessment and management of his symptoms.

Presenting Complaints

Table 1: Presenting Complaints as Reported by the Client

Duration Complaints
From 1-3 years Always worried about family members that nothing happen to them
From 1-3 years Fear of death remains. The news of the death of an acquaintance should not come
From 1-3 years About future, Especially business concerns
From 1-3 years I don’t think I will be able to handle the responsibility
From 1-3 years There is pain in the body. I can’t sleep
From 1-3 years The purpose of life is not understood. The brain is forgiven

History of Present Illness

The client’s problems started 5 years ago (2012) when his father suddenly passed away in a road accident. He was out of station at that time and got the news over the phone. He was devastated by the tragic news and went straight to home. Seeing the dead body and the funeral process was distressing for the client. It was difficult for him to cope with the situation as he was deeply attached to his father. Being the youngest child he received extra love and attention from his parents making him dependent on them. The loss shook the client completely and it took him almost 2-3 months to recover from it. He became close to his mother, did not leave his house and was least interested in his studies. Due to this his grades in the 1st year of his bachelors also declined. After 2 months of his father’s death, the client went back to the city where he was studying. He continued to take classes but could not keep concentration during them. He kept on thinking about his father, his loss and how helpless he was. His grades continued to decline in the second year as well. The client’s friends helped him recover through the process. He had a friend who also lost his father in early adulthood so the client paired with him and sought necessary advice from him. It took the client a year to recover from the loss although he still continued to miss him but he learned to function in a better way by accepting the harsh realities of life.

The client’s remaining 2 years of LLB went smoothly when in the last month of the degree, his brothers asked him to come back to his hometown and help his brothers in the business. The client was not interested in going back or becoming partners in the family business and refused his brothers politely. He took admission in LLM but his mental health deteriorated as he started to ponder upon future issues that he will not be able to handle the business or if his brothers would meet with an accident. He rejected the marriage proposal of his cousin as he did not feel like taking responsibility of anyone else. The constant worries made him sleepless at night and consequently performing inadequately in the day time. He would occasionally skip going to the court, rather stayed in his room lying down or reading the newspaper.

When the client shared his problems with his friends, they asked him to see a doctor. He visited a nearby hospital where the doctor recommended him to take the medicine ‘Alp’. The anxiolytic decreased his worrisome thoughts and increased his quality of sleep for 3 months after which the client discontinued the medicines as he did not want to get dependent on medicines. The client sought treatment from a psychiatrist who recommended him to consult a psychologist. He then came to the Centre for Clinical Psychology with the presenting complaints to get his symptoms treated.

The client did not report any sexual, physical or emotional abuse. No history of drug abuse, drug dependence, brain injury or accident was reported. Medical reports were also clear.

Background History

Family History

Father. Client’s father died at the age of 64 years in a road accident. He was diagnosed with diabetes and minor kidney problems. He was a short-tempered person but had immense love and care for the family. He always gave time to his wife and children and maintained a healthy bond with all of them. All of the client’s family members used to discuss their problems with his father as he used to give appropriate and expert advice. The client also had a nourishing relationship with his father who always gave the client extra attention as he was the youngest child. His father’s death was a great loss for the client and it took him almost 2 years to recover from the tragedy.

Mother. The client’s mother was a 59 years old housewife whose health greatly deteriorated after her husband’s death. She was diagnosed with hypertension, diabetes and arthritis in the past 4 years. The client became more attached to his mother after the death of his father. He felt an obligation towards his mother so called her every day, talking to her for at least 15-20 minutes. He reported that he did not like staying away from his mother but had to do it because of his job.

The client’s parents had a commendable relationship between them. Both of them had mutual agreement and understanding between them which helped them to raise their children easily.

First born brother. The client’s brother was 37 years old, married and running the family business along with the second brother. He was physically and mentally fit. According to the client he was now the father figure in the house. The client had a cheerful childhood with him. He sometimes had arguments with him on business matters but they were resolved constructively.

Second born brother. The client’s second brother was 34 years old, married man and was also involved in the family business. He was a quiet person who remained calm and composed. The client sought advice from him as they felt close to each other. There were seldom fights. Their relationship was respectful and enjoyable since the childhood and the client valued his brother a lot.

Third born sister. The client’s sister was 30 years old. She was married and was living in her home happily. She had 2 children. She was loved by her parents and her brothers and so had a loving relationship with the client as well. The client was extremely attached to her sister’s children.

Fourth born was client himself. 

            General Home Atmosphere. The dominant person in the client’s house was his father but after his father his elder brother took control. All family members cared for each other and sought advice from each other. The family business was the source of earning for the entire family. There were less arguments or fights.

Personal History

Birth and Childhood History. The client was born through normal delivery but did not remember any of the other information about his birth or early childhood. He recalled that he had pleasant memories of his family when he played with his brothers. He had a stimulating and nourishing childhood and received love and care from everyone. No neurotic traits were reported.

Educational History. The client started his education at the age of 6 years. He went to the same school as his brothers. He sought guidance from both of his elder brothers who also took care of him in the school. He had satisfactory relationship with the teachers and usually scored average marks. He made many friends with whom he used to play during the recess time and hangout after school timings. He passed his matriculation and Intermediate through the same school acquiring 70% marks in Matric while 79% marks in Intermediate. For his graduate degree he had to move to another city where he adjusted well but the death of his father in the first year caused his grades to decline significantly. During the bachelors he remained disturbed throughout but still managed to pass through all the exams. His teachers considered him a below average student and occasionally warned him for his attendance. He completed his bachelors and applied for masters in the same university. He was enrolled in the Masters program since one year and was managing to do his job and studies together.

Pubertal and Sexual History. The client achieved puberty at 15 years of age. He gained weight, his beard started growing and he experienced nocturnal ejaculations. He reported that he masturbated sometimes (approx. 2-3 times a month). The act was not distressing for the client.

Occupational History. He got employed after the completion of his bachelors degree. He reported that it was a strenuous job as the clients in the court usually pressurized him and his colleagues to take their case or charge less money. He still was interested in his job but felt lethargic due to insomnia. He had satisfactory relationship with his colleagues and seniors. The financial status of the job was also satisfactory for the client.

Pre-morbid Personality. The client was a cheerful and calm person before his symptoms emerged. He had lesser worries and he felt secure about his life. He met with people and his daily functioning was adequate. His thoughts were usually occupied by achieving his goals and becoming a successful lawyer. He had high frustration tolerance neither did he get irritated easily. He had good impulse control and also maintained his social relationships.

Psychological Assessment

The client was assessed on the basis of informal and formal testing.

Informal Assessment

Informal assessment comprised the following procedures.

Clinical Interview

The client was first asked to sign an informed consent to ensure that he was willingly taking the therapy and all information he gave was his own choice. He was interviewed to elicit information about his bio-data, presenting complaints, their durations, intensities and frequencies. He was also probed about his childhood history, family history, personal life and occupational functioning.  Details regarding his symptoms helped to understand their development and the client’s coping strategies to handle the stress.

Mental Status Examination

The client appeared to be in his early adulthood. He was a slightly short-heighted and bulky man. He had freckles over his face while his forehead had distinctly developed lines due to constant frowning. He was wearing ironed and neatly kept clothes. He sat in a hunched posture at the edge of the chair. His mood was euthymic. His rate of speech was fast and tone was loud. Adequate eye contact was maintained. His mood and affect appeared to be pleasant. His motor behaviors including gait, posture and gestures were appropriate. The client preferred to perform activities up to perfection but did not have any obsessions or compulsions. His abstract thinking and judgment was adequate. He was well oriented in time, place and person. He had fair insight about his problems.

Visual Analogue (Subjective Ratings)

The client was asked to rate his symptoms on 0-10 (0 = being the least problematic, 10 = most problematic) scale based on the severity and degree of problem each symptom was producing. The ratings also clarified that what symptoms had to be dealt first according to the client.

Table 2: Subjective Ratings of Symptoms According to the Client

Symptoms Ratings (0-10)
Constant worry/ Remaining preoccupied with worry 9
Uneasiness/ irritation/ agitation 9
Fear of dying or hearing someone else’s death news 9
Constant apprehension about the future 9
Inability to control worry 8
Fatigue, muscular tension 8
Sleep disturbances 8

 Worry Thought Record

The client was asked to maintain a worry thought record which helped in obtaining information about the content of worry, duration and maintaining factors regarding his worrisome thoughts. It also helped to bring into awareness his meta-worries and apply reattribution during the treatment.  The client was compliant in filling the record form while clarifications were elicited during the sessions.

Quantitative Analysis

Table 3: Frequency and Duration of Thoughts and Intensity of Emotions of the Patient

Area of WTR Pretreatment Rating
Frequency of worrisome thoughts 6-7 times a day
Intensity of beliefs on thoughts (NATS) 9
Qualitative Analysis

Table 4: Different Areas of Worry Thought Record and Patient’s Responses on Them

Area of WTR Functional Analysis
Triggering factors Discussions on future plans, memories of deceased father, hearing about someone’s illness, talking to brothers about business
Description of Worry Type I What will happen in the future?

What if someone passes away?

I cannot lose anyone else

How will the business carry on?

How will I handle future family?

What if I will not be able to support wife and children?

Description of Worry Type II

(worry about worry)

Why am I worrying too much?

I should not think this much?

I will go crazy by thinking continuously

I should be able to control my worrying

I keep on thinking all day long.

Emotions/ Physiological responses Worry, anxiousness, irritability, jitteriness
Behavior/ Response Distraction, sleeping, talking to someone, reassurance about everyone’s health

Formal Assessment

The client was formally assessed on the following scale.

Generalized Anxiety Disorder Scale (GADS-7)

The Generalized Anxiety Disorder Scale is used as a screening tool and severity measure for GAD. The scale assesses mood and somatic symptoms related to worry, control behaviors to stop worrying and Type I worry.

Quantitative Analysis

Table 5: Raw score and Severity of Problems as assessed by GADS-7

Raw score Cut off Severity (Pre-treatment)
18 15 Severe
Qualitative Analysis

The client’s score on the scale shows a high probability of having GAD. He was unable to control his worrisome thoughts which related to the assumption that something bad will happen. His scores on individual items also indicate that he was highly restless and felt keyed up most of the time during the day. The worry and its consequences were affecting his functioning severely in daily life activities as well.

Metacognitions Questionnaire

The metacognitions questionnaire is a self-report scale assessing different dimensions of metacognitive beliefs (beliefs about thinking). The scale is based on the metacognitive model given by Wells (1997). The test was administered to determine the degree of metacognitions the client was indulged in and what constituted her meta-worry. It helped in gaining more insight in the client’s worry about worry.

Quantitative Analysis

Table 6: Raw scores on Various Sub-scales Obtained by the Client on the Metacognitions Questionnaire

Subscales Raw Scores of Pre-treatment
Positive worry beliefs 37
Beliefs about uncontrollability and danger of worry 38
Meta-cognitive efficiency 16
General negative beliefs 23
Cognitive self-consciousness 16
Qualitative Analysis

The scores show that the client had both positive and negative beliefs about worry that maintained his habit of worrying but also caused him distress. He was also worried about the consequences of worrying constantly and thought that he may become sick because of them. The negative apprehensions and judgments constituted his worry and meta-worry.

DSM-5 Symptom Elicitation Checklist

The DSM-5 checklist for Generalized Anxiety Disorder (GAD) was used to validate the presence of symptoms in the client. The questions were directly asked from the client in order to probe more symptoms which he had previously not reported. The client fulfilled the first criteria of the disorder as he had been excessively apprehensive and worrisome about the future, business matters, family’s health, his own health, his responsibilities etc.. The second criteria was also confirmed as the client was unable to control his worry which made him employ control behaviors such as sleeping, talking to someone, seeking reassurance or calling home. The client also presented with restlessness, fatigue, insomnia, disturbed sleep, muscular tension and difficulty in maintaining concentration which met the third criterion of the disorder. All the symptoms produced discomfort in the client’s daily life and hence disturbed her everyday functioning which confirmed his diagnosis of GAD.

Diagnosis

  • (F41.1). Generalized Anxiety Disorder

Case Formulation

The client was a 27 years old man concerned about excessive worrying about his family, future,    job and everyday issues. He was experiencing fatigue, insomnia, muscular tension due to constant worrying for which he sought clinical advice. The Diagnostic Statistical Manual 5 proposes through its research that the disorder is more prevalent in individuals aged above 30 years. For middle adulthood, the major concerns of individuals with this disorder are health related concerns of family and self, finances and misfortune of children. The researches validate the client’s concern about his own health, his family members’ well-being, business matters and future (APA, 2013). The client was also near the median age of onset of the disorder, as per the manual, which makes him more prone towards having the disorder.

Beck (1985) states that people hold assumptions about dangerousness and make these assumptions after some negative life events. They become fearful of unknown. They also pay close attention to the threatening cues. This correlates with the present client as he started to face problems after the death of his father. His father’s death was a negative and traumatic event for him which may have triggered excessive worrying and anticipation of more negative life events in his life.

Kendler, Hettema and Butera (2003) propose through their research that individuals who have experienced deaths, multiple episodes of loss and separation from near relatives have a higher probability of developing Generalized Anxiety Disorder. These individuals usually anticipate similar life events in the future and thus become more prone towards the symptoms of excessive worrying, remaining tensed and foreseeing negativity. In case of the client, he had experienced the death of his beloved father. Due to the past, he expected to lose someone in the future as well because of a death or a catastrophe.

Wells (1994a, 1995) distinguishes between Type I worry and Type II worry which is present specifically in clients with GAD. According to him, Type I worry concerns external daily events while Type II worry is basically worry about worry. The combination of the two types of worry and subsequent positive and negative beliefs about worrying together maintain the cycle of GAD and worsens the symptoms. Similarly, the client was also worried about daily life concerns compromising his Type I worry. But on the other hand he had both positive and negative beliefs about worry creating cognitive dissonance and thus anxiety in him. The constant back and forth movement of the client between Type I and II worry was being distressful and symptomatic for him.

Idiosyncratic Case Conceptualization (Wells, 1995)

Idiosyncratic Case Conceptualization

Management Plan

Short-Term Goals
Rationale Therapeutically Applied Techniques
Engagement of the client in therapy and building a trustworthy relationship between therapist and client Supportive work/ Psychoeducation

Therapeutic Alliance

Collaborative Empiricism

Eliciting content of Type I worry and Type II worry to form idiosyncratic case  conceptualization Guided Questioning

Advantages/Disadvantage Analysis of worry

Identification of Control Behaviors

Worry Thought Record

Informing the client about the etiology, development, symptoms, mode of treatment and prognosis of the disorder Psycho-education

Socializing with the CBT model of GAD

Suppression experiments

Provide information to the client about normal and pathological worry Normalizing worry
Disconfirming positive beliefs about worry and uncontrollability about worry Worry time (Behavioral Experiment)

Challenging uncontrollability appraisals/beliefs

Questioning the evidence and mechanism

Managing Type I worry Problem-solving cycle

Distraction

Managing somatic complaints such as fatigue, sleep problems, restlessness and body aches Sleep hygiene

Deep breathing

Progressive Muscle Relaxation

Relapse Prevention Therapy Blueprint
Long Term Goals

Continuation of short-term goals

Follow-Up sessions

Session Reports/ Management Plan

Session No.1                                                 Time of session: 45 minutes

Session Agenda

Develop therapeutic alliance, History taking, Mental Status Examination, Symptom elicitation and subjective ratings

Techniques

Informed Consent and History taking

Rationale: To gather information about the client’s past life, and development of symptoms. Procedure: Informed consent was obtained to ensure that the client was willingly taking the therapy and providing information. The interview was held with the client to elicit information relevant to his current and past life. Interview consisted of both open-ended and close-ended questions. The client reported the information without hesitation. It was made sure that the client was comfortable while sharing his issues and all sensitive issues were discussed with care. Outcome:  The interview was helpful in producing detailed information about identifying data, personal life, education, sexual history, pre-morbid personality and history of present illness. It gave in-depth clarification about client’s symptoms, duration and frequency of symptoms, etiological factors as well as the maintaining factors. History was elicited to gain knowledge about the client’s daily life functioning before and after the emergence of symptoms. Family history was elicited to identify the support system for the client.

Mental Status Examination

Rationale: To assess the client in multiple areas of functioning. Procedure: Some of the information was gathered by observing the client’s behavior, actions and speech while others were directly asked from the client. Outcome: The client had appropriate behavioral functioning except the presence of a pre-occupation with his bodily symptoms and reactions.

Symptoms Elicitation and Subjective Rating

Rationale: To get a clearer picture of the client’s symptoms and his own rating about each symptom. Procedure: The client was asked to rate his symptom on a scale of 0-10 where 0 was least problematic and 10 was the most. Outcome: The client prioritized his symptoms according to their severity which helped in determining which symptoms were to be dealt first.

Therapeutic Alliance

Rationale: To bring both the therapist and client at ease and on good terms, trust each other, be open towards one another and show respect. The alliance is necessary to create a sense of understanding, confidentiality and regard between both individuals so that blocks and hesitance can be avoided. Procedure: The therapist tried to build a professional yet empathetic relationship with the client to make him comfortable during the therapy. The therapist maintained a non-judgmental and concerned attitude towards the client’s issues. The client was allowed to give his own perspectives regarding the issue and tell all the information relevant to his symptoms. He sometimes had to be re-directed towards the major issues when he kept talking about minor irrelevant details. The client was also provided with the feeling that the therapist completely understood what he was going through and how the symptoms were affecting him negatively. The client was further engaged in therapy by asking about his family and personal history. Relevant information regarding the symptoms’ precipitating and maintaining factors were probed. Rapport was built by actively listening to the client and providing him with unconditional positive regard. Outcome: The client trusted the therapist and problems were discussed freely.

Homework given: Worry thought record was given to monitor the quantitative and qualitative aspects of the client’s worries.

Session No.2                                                Time of session: 45 minutes

Session Agenda

Differential diagnoses, Formal assessment (Generalized Anxiety Disorder Scale and Metacognitions Questionnaire)

Homework review: The client’s worry thought record was reviewed. The content of worries and client’s reactions were seen.

Techniques

Differential Diagnoses (American Psychological Association, 2013)

Rationale: To get a clearer picture of the client’s symptoms and rule out irrelevant diagnosis. Procedure: Symptoms specific to the disorder were asked. The cluster of anxiety disorders were thoroughly investigated to reach to a final diagnosis. Outcome: Normal worry, Major Depressive Disorder and Panic Disorder were ruled out and GAD was confirmed.

Formal assessment (Generalized Anxiety Disorder Scale-7)

Rationale: To elicit more information about the client’s symptoms using a standardized tool. Procedure: GADS-7 was a 7 item questionnaire which was explained to the client. He was told about how to answer the questions and how he was supposed to respond. He completed the questionnaire in 5 minutes and was easy for him. Outcome:  The scale was helpful in identifying the degree of worries client felt.

Formal assessment (Metacognitions Questionnaire)

Rationale: To elicit information regarding the client’s content of worries and how much they affected the client. Procedure: The procedure to attempt the questionnaire was explained to the client. He was given ample time to fill it. All ambiguities were removed. Client comfortably did the complete questionnaire in 30 minutes. Outcome:  The test was administered to determine the degree of metacognitions the client was indulged in and what constituted his meta-worry. It helped in gaining more insight in the client’s worry about worry. The scores show that the client had both positive and negative beliefs about worry that maintained his habit of worrying but also caused him distress. He was also worried about the consequences of worrying constantly and thought that he may become sick because of them. The negative apprehensions and judgments constituted his worry and meta-worry.

Session No.3                                       Time of session: 45 minutes

Session Agenda

Psycho-education, socialization, advantages and disadvantages analysis of worrying, identification of control behaviors.

Review of previous session: The previous session was reviewed by summarizing the client’s symptoms and his performance on the questionnaires. This helped in bridging the gap between previously told symptoms and new information which was to be provided in the present session. The client diagnosis was also confirmed to him as he wanted to know if his symptoms were real.

Techniques

Psycho-education (Wells, 1997)

Rationale: To orient the client towards his symptoms, their development, precipitating factors, treatment plan and prognosis.  Procedure: Psycho-education was conducted to address queries of the client about the illness i.e. what it is, why was it happening, what other symptoms could emerge, what should be the measures taken, are medicines necessary, what can be the psychological treatment plans, how long will the client take to recover and what is the probability of complete eliminations of symptoms. The information was provided under the light of recent researches and the psychiatric manual. The process of psycho-education was also accompanied by informing the client about what was required from him. The role of the therapist was clarified and client was told to help himself at maximum. Therapy protocol was discussed i.e. the no. of sessions, duration of sessions and expectations of the client from the therapist. Importance of homework assignments was also discussed. Outcome:  The client was convinced and relaxed after he was psycho-educated. He asked multiple questions about how the therapy will take place and for how long. His questions about the prolongation and healing of his symptoms were also addressed.

Socialization (Wells, 1997)

Rationale: To make the client understand the development and process of his disorder. Procedure: Wells (1997) emphasizes the importance of socializing the client with the model of GAD. According to him, selling the concept of meta-worry and the maintaining factors of worrying help the client to know what the actual problem is. In the socialization process, the client was told that his daily thinking circulates between type I and Type II worry which are strongly help by his positive meta-beliefs but also become problematic for him when negative meta-beliefs are activated. He was also told that it was not about the content of worry that is causing the issue but it is the act itself which is the challenge. The client agreed upon the cycle of worrying and understood it completely. He was then educated about the points at which therapy had to be employed and change had to be introduced. Outcome: The model had a great impact on the client as he felt that his symptoms were being understood and there was a solution for them. He understood the concept fairly well and took the model along with himself to review it again.

Advantages and Disadvantages analysis of worry (Wells, 1997)

Rationale: To identify the positive and negative beliefs the client had associated with worrying. Procedure: The analysis was carried out during the session by creating a double column and verbally eliciting information regarding his beliefs. The beliefs that made him carry on with worrying were put under his positive beliefs while the beliefs that made him distressful about his worrying were included in negative beliefs. Outcome: The procedure itself instilled slight insight in the client about his views regarding the thought processes. It also gave the client insight about beliefs of danger and appraisal of uncontrollability.

Identification of control behaviors (Wells, 1997)

Rationale: To identify the behaviors of client which he used to tackle with his worry. Procedure: It was done through verbal strategies by asking the client about his behaviors when he worried too much or felt irritable because of worrying. Initially, the client had to be briefed about the purpose of control behaviors, after which he successfully identified his control behaviors. The questions introduced his ways to deal with his stress or put a stop to his act of worrying. Outcome: The Control behaviors were identified so that they may be eliminated and the client can learn to deal with distress and worry through constructive procedures.

Homework given: The CBT model of GAD was given so that the client may review and understand it. He was also given a copy of the advantages and disadvantages analysis so that he can go through his verbatim again.

Session No.4                                                      Time of session: 45 minutes

Session Agenda

Suppression experiments, guided questioning, What if experiment, Normalizing worry

Review of previous session: The client was inquired about any queries he had regarding the last session. Questions relating to his disorder were addressed again. CBT model was reviewed so the symptoms can be addressed again and therapy protocol may be continued.

Techniques

Guided Questioning (Wells, 1997)

Rationale: To elicit the meaning, client attached to the act of worrying. Procedure: The method was used as the client was initially unable to tell if he was being worried by his worrying. He would reply with one sentence that he worries a lot but could not tell if he was being affected by worrying. Guided questioning helped in clarifying the client’s view about his act of worrying. Questions relating to Type I worry were asked from multiple perspectives which were helpful in identifying the Type II worries. Outcome: It helped to control the worry as the client understood the content well.

Suppression experiments (Blue-rabbit technique) (Wells, 1997)

Rationale: The experiment was used to make the client realize the paradoxical effects of controlling worry. Procedure: At first, the client was asked to close his eyes for 3 minutes and then try to think of a blue rabbit. Once the client was able to achieve it, now he was asked to close his eyes and try NOT to think of a blue rabbit. The rationale of the technique was kept hidden. He was then asked to open his eyes and tell if he was successful in doing the job. The client reported that all the time he was thinking of a blue rabbit although he had never even seen one. The purpose of the technique was then explained to the client that the worries rebound in the same manner as the image of the blue rabbit, whenever the client tries to control them. The more he wanted to get rid of the thoughts (suppress the thoughts), the more they come back in his mind. Outcome: The experiment was helpful in making the client understand the reason of his worrisome thoughts.

What-if experiments (Wells, 1997)

Rationale: To make the client understand the consequences of excessive worrying. Procedure: A situation was taken in which the client was asked to tell what he dreaded. The situation was taken further until the client had imagined worst possible consequences. At that point, the client was stopped and made to realize that excessively worrying about a matter always produced negative and worst possibilities in the mind, even if there was a least chance of that scenario to happen.  Outcome: The experiment had to be done in multiple sessions to convince the client. The client realized its validity after 2-3 experiments had been done. It proved to be effective.

Normalizing worry (Wells, 1997)

Rationale: The client had to be specifically educated about the difference between normal worry and pathological worry. Procedure: He was initially told that everyone in the world worries to some extent. All individuals have worries related to their education, children finances, home, job, relatives etc. But then he was explained the difference by putting the phenomenon of worrying on a continuum where at one end worrying was beneficial for the individual but on the other it was dangerous and problematic. He was educated that worry can be helpful up to a certain point but excessive worry leads to no positive outcomes, rather a continuously stressed brain. Outcome:  The normalization helped in making the client understand to create a balance in his worrying thoughts.

Homework: The client was asked to do the blue rabbit technique again at home. This was recommended so the client can be convinced that trying to waiver the thoughts may result ina rebound.

Session No.5                                 Time of session: 45 minutes

Session Agenda

Verbal Reattribution (Questioning the evidence), Sleep hygiene

Homework Review: The client was asked if he practiced the blue rabbit technique at home and its effects. He told that he practiced it multiple times and each time he was not unable to NOT think about the blue rabbit. He was convinced that getting rid of the thoughts will end up in the thoughts coming again.

Techniques

Verbal Reattribution (Questioning the evidence) (Wells, 1997)

Rationale: To question the client’s beliefs of going crazy because of excessive worrying. Procedure: The client had a belief that he would go crazy if he worried this much and that worrying to this extent was not normal. The increased meta-worried intensified his symptoms. In order to challenge his belief, the client was asked to list down the evidences he had in favor of getting mad or going crazy because of the thought. He was also asked to write the instances in which anybody he knew went crazy because of overthinking.  Outcome: The experiment helped in revealing that the client was holding his belief without any firm evidence or basis. It ensured the client that his belief was illogical and decreased client’s degree of belief in his thought.

Sleep hygiene tips

Rationale: To manage his sleep timings and measures he should take to have a better quality of sleep. Procedure: The client had a habit of lying down on his bed and keep on thinking about future events and possible negative outcomes. For this purpose, he was told to use the bed for sleeping purpose only and sit upright on a chair when he felt like thinking upon future issues. He was told that empirical studies and research proves that negative thinking is least intrusive when the individual is in an undesirable and uncomfortable posture, while they become more emotionally charged when the person thinks about them in relaxed positions. Another research was quoted that when a person lies in the bed worrying, he/she associates the bed with negative thinking. In response every time he/she uses the bed, she starts to think negatively. The research evidences were striking for the client and she agreed to use her bed only for sleeping purposes. All other activities were carried in their appropriate ways. Other than these, tips regarding healthy diet, sleeping hours and sleep timings were also given. Outcome: The instructions were clearly understood by the client

Homework: Sleep hygiene tips were given to be practiced at home. He was also asked to try to challenge his beliefs at home such as his belief that he will lose control or will be unable to handle his thought processes.

Session No.6                                                  Time of session: 45 minutes

Session Agenda

Challenging uncontrollability of thoughts, worry time

Homework Review: He was asked about the improvement in his sleep. He told that his sleep was slightly better now and he was trying to implement all the tips on himself. Moreover, he was inquired if he tried to restructure his belief by questioning the evidences he had for them. He was able to modify the belief that he will lose control over himself as he did not have any strong evidence in favor of it.

Techniques

Challenging Uncontrollability of thoughts (Wells, 1997)

Rationale: To make the client realize that his thoughts processes were in his control. Procedure: Initially, the client’s negative beliefs about worrying were modified. He was asked about the times he could switch her worrying ON or OFF. The client replied that he could not control her worrying besides trying. He was then questioned about the times he distracted himself or got himself busy in other mental activities. It was those times when he could switch OFF his worrying thoughts. Outcome: The client realized about his own controlling behaviors after the facilitation of the therapist and was convinced that worrying can indeed be controlled.

Worry time

Rationale: To make the client focus on his worries and thoughts only once a day and also to strengthen his belief that worrying or not worrying was in his control. Procedure: He was asked to specify a certain time of day in which he will worry about the problems and then find suitable solutions for them. At the other times of day, when he worried about daily problems, he was asked to postpone the worry until the worry time and then utilize that time for constructive work. Outcome: The controlled worry periods also helped to loosen the client’s belief that worrying itself is uncontrollable.

Homework: The client was asked to practice worry time at home as well as convince himself that the worrying was under his control and he can lessening his degree of worrying if he wants to.

Session No.7                                 Time of session: 45 minutes

Session Agenda

Verbal Reattribution (Questioning the mechanism), Progressive Muscle Relaxation

Previous session and Homework Review: The client practiced worry time at home. He gave the feedback that he was unable to worry in the specified time as well. He was successful in postponing worry and also in lessening it.

Techniques

Verbal Reattribution (Questioning the mechanism) (Wells, 1997)

Rationale: To make the client realize that his thoughts were illogical and not based on true processes. Procedure: He was asked about the procedure through which one goes crazy. The client could not recall any known person that had gone crazy due to worrying. Outcome: The client was then briefed that the process of going crazy or acquiring a severe condition was different rather than only due to worrying. He was convinced that his beliefs were not based on facts rather on assumptions he made himself.

Progressive Muscle Relaxation

Rationale: To relieve the client’s fatigue and muscular tension. Procedure: The client was told to practice at least 2 times during the day to attain maximum relief from somatic symptoms. The muscles of forehead, neck and shoulders were emphasized during the relaxation exercise so that he felt the difference between the tensed and relaxed muscles of the body. Outcome: The relaxation exercise was adequately understood by the client and he planned to carry it out daily.

Homework: Instructions for muscle relaxation technique were given to the client so he may follow them at home. He was also asked to monitor his thoughts and check if they were realistic or not.

Session No.8                                  Time of session: 45 minutes

Session Agenda

Problem-solving cycle, distraction techniques

Homework Review: The client practiced  the relaxation exercise at home and reported that it created a significant difference in his muscular tension and that it was a physically and mentally relaxing time for him.

Techniques

Problem solving cycle

Rationale: To make the client constructively find solutions for his issues, problem-solving cycle was explained to him. Procedure: The cycle was described by incorporating examples of the client’s life. The steps included identifying the problem on which he worried, finding all possible solutions and then selecting the most plausible and beneficial solution. Through the cycle, the client was told about the appropriate and worry-free resolution of the problem and that worrying alone did not result in finding any kind of solution. It educated the client about the step at which he selected the problem and after which worrying will not be beneficial in any way and so the cycle puts an end to worrying. Outcome: The client understood the cycle, but found it difficult to implement for every small worry. He tried to apply it in maximum issues as possible.

Distraction techniques

Rationale: To manage client’s worry when he found it unable to stall it. Procedure: The times when he found it difficult to stop worrying, he was asked to engage in other mental activities such as talking to someone, reading a magazine, watching television, going out with friends etc. Outcome: Distraction was effective in controlling client’s worrying and further helped him to reduce the duration of worry.

Homework: The client was suggested to follow the problem-solving cycle at home and use it for every possible problem. He was also suggested that the problem-solving cycle will help him in handling difficult situation with more efficiency.

Session No.9                                             Time of session: 45 minutes

Session Agenda

Therapy blueprint, post assessment

Homework Review: The client implemented the problem-solving cycle in various issues and reported that it helped him to worry to a certain extent after which he left it when he found no solutions to the problem.

Techniques

Relapse Prevention and Therapy Blueprint

Rationale: To aid the client in future situations, in case of any relapse. Procedure: After the client was gone through all the techniques and he had practiced them at home, he was again explained all the techniques in one session and how it had helped him in dealing with the symptoms. He was given a therapy blueprint which summarized the major techniques done, situations in which that technique could be applied and its procedure.

Post-assessment

Visual Analogue

Subjective Ratings of Symptoms According to the Patient

Symptoms Pre-Assessment Ratings Post-Assessment Ratings
Constant worry/ Remaining preoccupied with worry 9 5
Uneasiness/ irritation/ agitation 9 4
Fear of dying or hearing someone else’s death news 9 5
Constant apprehension about the future 9 3
Inability to control worry 8 4
Fatigue/ muscular tension 8 2
Sleep disturbances 8 1

 Generalized Anxiety Disorder Scale (GADS-7)

Raw score and Severity of Problems as assessed by GADS-7 at a pre-treatment and post-treatment level

Raw score Cut off Severity
Pre-treatment rating 18 15 Severe
Post-treatment rating 6 5 Mild

 

Meta-Cognitions Questionnaire

Raw scores on Various Sub-scales Obtained by the Patient on the Metacognitions Questionnaire

Subscales Raw Scores of Pre-treatment level Raw scores at Post-treatment level
Positive worry beliefs 37 15
Beliefs about uncontrollability and danger of worry 38 10
Meta-cognitive efficiency 16 2
General negative beliefs 23 8
Cognitive self-consciousness 16 5
References;
  • American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. Fourth Edition, Revised
  • Comer, R.J. (2006). Abnormal Psychology, (6thed.). Princeton University, US
  • Kendler, K. S., Hettema, J. M., Butera, F., Gardner, C. O., & Prescott, C. A. (2003). Life event dimensions of loss, humiliation, entrapment, and danger in the prediction of Onsets of Major Depression and generalized anxiety. Archives of General Psychiatry, 60(8), 789. doi:10.1001/archpsyc.60.8.789
  • Wells, A. (2013). Cognitive therapy of anxiety disorders: A practice manual and conceptual guide. John Wiley & Sons.

Case 2

Case Summary

The client was a 27 years old man educated up to MBA and working as an assistant officer in a a bank. He belonged to an upper middle class family. He came to the Centre for Clinical Psychology to seek treatment for his symptoms of increase heart rate, palpitations, dizziness, lightheadedness, fatigue, feeling of choking, bloated stomach, high blood pressure, fear of dying and a preoccupation of having future panic attacks since a period of 2 months. He was assessed through a clinical and diagnostic interview, panic diary, visual analogue and panic rating scale. After detailed assessment he was diagnosed with Panic disorder. His treatment plan included in-depth psycho-education, behavioral and verbal reattribution, cognitive restructuring, coping statements and relaxation exercises. The treatment was helpful in subsiding the client’s symptoms as evident by the discrepancy between pre and post assessment.

Bio data

Name: H.K.

Age: 27 years

Gender: Male

No. of siblings: 3

Birth Order: 2nd

Education: MBA

Occupation: Assistant Officer in Bank

Marital Status: Unmarried

Religion: Islam

Informant: Client himself and his mother

Reason and Source for Referral

The client came to the Centre for Clinical Psychology upon the recommendation of his sister. He complained of increased heart rate, palpitations, dizziness, lightheadedness, fatigue, feeling of choking, bloated stomach, high blood pressure, fear of dying and a preoccupation of having future panic attacks. He was referred to a trainee clinical psychologist for the assessment and management of his symptoms

Presenting Complaints

Table 1: Presenting Complaints of the Client as Reported by Him.

Duration Complaints
From 2 Months Suddenly panic sets in
The heart beats faster. Blood pressure rises
Sweating and body trembling
It is difficult to breathe. Looks like I’m not breathing
Feels tired. Feeling dizzy
Stomach upset
Looks like I’m going to die
There is a risk of recurrence

History of Present Illness

            The client started to experience the above stated symptoms 2 months back when he experienced a major stressful event in his life. Before the event, the client rarely presented with any of the issues he reported. The client was living in Dubai and in March 2017, he went on a trip with his friends where he met with a deadly prank during night time. He was present in a car with three of his friends and they were going on an empty road. Two of the friends in the car knew about the prank while the client and one of his other friends did not know what was about to happen. The prank was initiated by acting out that the car had broken down and all the members had to leave the car. The client also did as said but after leaving the car they were suddenly chased by a guerilla. The guerilla was actually their friend dressed in a costume. The client and his other friend ran for their lives but could not find help or shelter. They were threatened by the guerilla for almost an hour while the prank took almost 3 hours to finish. It became a life-threatening event for the client while he tried to save his life for the most difficult 3 hours of his life. After considerable time had lapsed, the client and his friend were rescued by the other friends where they were told that they had been pranked. Initially the client was irritated by the whole event but eventually they all laughed it out. At the same night, the client experienced increased heart rate, sweating, palpitations, numbness and dizziness for the first time. He went to his uncle in whose house he was staying and asked him to check his blood pressure. The client’s blood pressure was high for which his uncle recommended him to drink plenty of water and try to sleep. The client was able to sleep after half an hour and woke up fresh in the next morning. After a few days the client visited the place again, where he was pranked for his satisfaction. He roamed around the whole place and felt content that nothing had happened. According to him, he wanted to pack-up the episode without getting affected from it anymore.

Besides the client’s efforts of forgetting the prank, he experienced the same symptoms after a week for which he consulted a cardiologist. He suspected a heart condition so got his ECG and blood tests done. The tests were clear but the doctor prescribed him with an anxiolytic (Indral 0.5 mg). The client started taking the medicine but read about its side effects on the Internet and thus decided to wear it off slowly.

The client started to experience his symptoms repeatedly (increased heartbeat and feeling bloated after eating, sweating while sitting in the office, dizziness while going to sleep) after one week and they increased to 3-4 times a week which made the client hypervigilant towards his problems. He feared that he would have a heart attack or would die due to his symptoms. Due to the constant concern he started to surf the Internet to know more about his problems. The websites provided him with loaded psychological words such panic attacks and depression and he diagnosed himself with Panic disorder. Since then he became more concerned about his symptoms, finding treatments on the Internet and also calling his family in Pakistan. He started to avoid the situations where he experienced the attacks which slowly started to disturb his occupational functioning. Leaving repeatedly and being constantly vigilant about his bodily symptoms made him less attentive towards his work. He started to keep a water bottle with him to use in the time of these attacks.  He consulted a general physician 3 times and got his blood tests and EKG done. The reports were normal and doctors told him that there was nothing to be worried out. The symptoms were still evident which made him and his family tensed about the situation so they decided to consult a psychologist.

The client came to Pakistan in May 2017, where his sister recommended him to get guidance from a psychologist. Hence, he came to the Centre for Clinical Psychology to seek assessment and treatment. He reported no history of physical or sexual abuse or use of any illicit drugs.

Background History

Family History

Father. The client’s father was a 61 years old, retired WAPDA official. He was in good health and was a calm-natured person. He did not suffer from any psychological illness. He once experienced heart symptoms but recovered in a month after seeking treatment and taking medications. His relationship with his children was congenial. He was involved with them and took care of their needs. His relationship with the client as well was satisfactory where both of them loved each other and discussed matters cooperatively.

Mother. The client’s mother was in her fifties and was working as a principal in a well-reputed school. She did not have any medical or psychological illness. She was a composed lady who worked hard to raise her children. She dedicated her time for the appropriate upbringing of her children. Her relationship with the client was also congenial as the client discussed most of his issues with his mother. She was the first person to know about the client’s symptoms. She remained concerned about the client as he was far and contacted him occasionally to keep in touch with him. They talked to each other almost daily through calls.

First born Sister. The client’s sister was 29 years old who had done her MPhil in Environmental Sciences. She was currently employed and unmarried. She had a friendly nature and also was strongly attached to the client. She reported that her brother had grown a little distant after he moved abroad but they still talked frequently and had frankness between them. The client also readily discussed his matters with his sister. They cared for each other and provided themselves if the other needed help.

Second born was client himself

Third Born brother. The client’s brother was 23 years old and currently enrolled in the last year of BBA. He was a social and outgoing boy. He enjoyed with the client a lot and also missed him after the client shifted. The client felt attaches to his brother and also provided him with the relevant guidance in studies and other matters of life. They talked over video calls and through texts occasionally. The client’s brother took the client as a role model to follow.

Fourth born brother. The client’s younger brother was 19 years old and in the first year if BBA. He was also a cheerful and fun loving person. He was an obedient son who showed respect towards the client. Both of them had a strong bond between them and played cricket and indoor games with each other whenever they met. The client had a nourishing and fatherly attitude with his younger brother keeping them bonded with each other.

Personal History

            Birth and Childhood History. The client was born after a complete gestation period of 9 months and through a normal delivery. He had normal birth weight and color. He achieved his developmental milestones at appropriate time but started to walk slightly earlier. He had a nourishing and playful childhood when he used to play with his sister, cousins and neighbors. He was a cheerful boy who adjusted easily with strangers. No neurotic trait was reported by the client.

Educational History. The client started his education at the age of 6 years. He was an average student throughout his educational life. His primary education was rich with knowledge and he was an eager child to go to school. His teachers never complained of him rather appreciated him in all parent- teacher meetings. No incidences of bullying were reported rather he was also good at sports. The client completed his matriculation with above average marks and got admission in the college of his own choice. His Intermediate also passed with average marks and a good image in the college. After Inter he decided to do BBA and got into a well-reputed university for graduation. He made many friends, was outgoing and also maintained his GPA in average lines. He completed his MBA from the same university and achieved above average marks due to his interest in the subject. The client and his sister both reported that the client was an easy going child especially in studies as he studied himself and consulted their mother for any kind of guidance.

Pubertal History. The client achieved puberty at approximately 15 years of age when he started to grow a beard, experienced changes in his genitals and his voice got heavier. He reported some instances of masturbation but told that he preferred to remain away from such acts. Homosexual or heterosexual experiences were not reported.

Occupational History. The client was working an assistant officer in a Bank situated in Dubai, UAE. He had been employed since one year and was content with his job. He reported that there were stressful times at work as well when the load of work increased and he had to work for more hours. He sometimes skipped his extracurricular activities due to work. He had satisfactory relationship with his employer and colleagues. He went out on trips and dinners with his friends and co-workers. He was social and did not face any major issues with his fellow employees. The client had been facing some problems due to his symptoms since the last 2 months at work as he avoided sitting in the office when his symptoms occurred or he would exit the room. He usually went to go for a walk or have a cool drink. He also took 3-4 half day leaves since his symptoms started to emerge. He did not discuss any of issues with his colleagues or boss as he decided to seek treatment on a personal level.

Hobbies/Interest. The client was athletic and enjoyed sports from his childhood. He played cricket while he was in Pakistan. After moving to Dubai, he was unable to continue playing cricket but indulged himself in swimming and gym activities. He regularly dedicated time to physical activities but reduced them after the symptoms started emerging.

Pre-morbid Personality. The client was social and outgoing before his symptoms started to show. He was eager to go on trips, have fun and feel energetic. He was confident and never felt more focused or attentive towards his health or body. He used to go for exercise, extracurricular activities (gym, swimming, outdoor games) and did not hesitate in physical exercises. Even at times of stress, the client used to act cool and calm because he took life problems as a challenge but nothing to stress about. He had a high frustration tolerance and less impulsivity. He took decisions steadfastly rather than remaining confused.

 Psychological Assessment

The client was psychologically assessed on informal and formal basis. Informal assessment included:

  • Clinical Interview
  • Mental Status Examination
  • Visual Analogue
  • Panic Diary

Formal assessment comprised of:

  • Panic Rating Scale

Clinical and Diagnostic Interview

Informed consent was obtained from the client and his mother to report all information willingly and to ensure that the client was taken therapy according to his consent. The interview was conducted with the client and his mother. The interview gave detailed information about identifying data, personal life, education, sexual history, pre-morbid personality and history of present illness. The interview was beneficial in obtaining information of client’s symptoms, duration and frequency of symptoms, etiological factors as well as the maintaining factors. History was elicited to gain knowledge about the client’s daily life functioning before and after the emergence of symptoms. Family history was elicited to identify the support system for the client. History was also validated from his mother who provided with more information about the client’s behavior. The interview as a whole provided information about the client’s current health and to devise a case formulation and a management plan.

Mental Status Examination

The client was an average heighted young man appearing to be in his late twenties. He was well-groomed and wore clothing which was adequate according to the weather. The client kept on fidgeting with his hands and shaking his legs. He appeared to be anxious as he spoke in a loud tone and his rate of speech was fast. He maintained adequate eye contact and appeared to be attentive towards the therapist. His orientation of time, place and person was intact. He had adequate short-term and long-term memory. He had insight about the psychological nature of illness.

Visual Analogue (Subjective ratings)

The client was asked to rate each of his symptoms on a scale of 0 to 10 to get information about the level of disturbance each symptom was causing and what intensity it had for him. In the scale 0 meant that the symptom was least intrusive in his life while 10 meant that it was the most.

Table 2: Ratings of the Symptoms According to the Client

Symptoms Pre-treatment Ratings (0-10)
Physical and physiological symptoms (Increased Heart rate, sweating, dizziness, breathlessness, numbness, choking) 10
Fear of having a heart attack 9
Fear of dying 9
Fear of having a panic attack in the future. 9

Panic Diary

The panic diary was given to the client in order to analyze frequency and intensity of panic attacks, as well as triggering factors, bodily sensations, emotions and his misinterpretation of negative thoughts as well as coping strategies used. He was explained the whole chart and was asked to fill it after every attack he had. The client filled the chart cooperatively which clarified more aspects of the panic attack (see Appendix B).

Quantitative Analysis

Table 3: Areas of the Panic Diary and the Client’s Responses

Areas of Panic Diary Pre-treatment Rating
Frequency of panic attacks 3-4 per week
Duration of panic attacks 5-10 minutes
Intensity of belief in misinterpretation of symptoms 9/10 on average
Qualitative Analysis

Table 4: Areas of the Panic Diary and the Corresponding Client’s responses

Areas of Panic Diary Functional Analysis
Precipitating factors Sitting in the office, Lying on bed at night
Bodily symptoms during panic attack Increased heart rate, dizziness, breathlessness, sweating.
NATs or misinterpretation of symptoms I will die, I’m having a heart attack
Feeling/Emotions Fear, anxiety
Coping Strategies Checking blood pressure, drinking water, getting reassurance from uncle

Formal Assessment

Panic Rating Scale

The panic rating scale was administered to ensure the presence of panic attacks and related behaviors and physiological arousal of the client (Wells, 1997). It is a self-administered test consisting of 4 items which assess panic attacks from various dimensions.

Quantitative Analysis

Table 5: Item Analysis of the Panic Rating Scale

Item # Statement Pre-Treatment Rating
1 Number of panic attacks in the last week 5
2 Frequency of avoidance behaviors 7-8 times
3 Average rating of coping strategies 60% on average
4 Average rating of beliefs on anxious thoughts 45% on average
Qualitative Analysis

The scale shows that the client had five panic attacks in a week and was also inclined towards avoiding such situations. His coping strategies were mostly, controlling his breathing, using medications, repeatedly checking his pulse, and trying to be with someone for reassurance or immediate help. The thoughts accompanying and maintaining the client’s attacks were mostly that he may have a heart attack or a stroke and fear of suffocation.

Diagnosis

300.01 (F41.0): Panic Disorder, unexpected panic attacks.

Case Formulation

The client was a 27 years old young man complaining of increased heart beat, sweating, dizziness, lightheadedness, choking, bloated stomach, fear of dying or going crazy and remaining preoccupied of having another panic attack in the future. He was diagnosed with Panic Disorder because of the symptoms and etiological factors. The risk of developing a panic disorder also includes environmental disorders (American Psychiatric Association, 2013). These can be identifiable stressors in months before the first panic attack such as interpersonal difficulties, physical well-being and negative experiences. In the client’s case as well, he experienced a grave incidence which risked his life. The prank caused him to think that he was going to die due to a constant threat. This may have triggered his panic attacks and the symptoms that started to appear just after the incident.

Goldstein and Chambless (1978) proposed a learning theory that a fear of impending panic or other feared bodily sensations, labeled “fear of fear.” From this perspective, innocuous bodily sensations become classically conditioned to the aversive physiological arousal associated with panic attacks. Because these classically conditioned sensations could trigger an unwanted panic attack across situations, individuals avoid various situations out of fear that they would be unable to cope with their panic if it were to occur in that situation. In the client’s case, his heightened physiological sensations had become associated with exacerbated bodily symptoms which resulted in a panic attack.

In addition to the above theory, Goldstein and Chambless (1978) also give more cognitive elements as a part of their theory as they propose that individuals who experience a panic attack are hyper alert towards their bodily sensations and interpret them as a sign of upcoming panic attack. The client under therapy also presented with the same cognitions and behavior. He became excessively concerned about his heartbeat and breathing and attempted to check them after every 20-30 minutes. He would usually check his blood pressure by a sphygmomanometer or ask his uncle to check his pulse. The act of being hyper alert caused him to experience and notice his symptoms more as compared to if he ignored them.

Bouton, Mineka, & Barlow (2001) propose that Panic Disorder develops because exposures to panic attacks causes the conditioning of anxiety (and sometimes panic) to exteroceptive and interoceptive cues. This process is reflected in a variety of cognitive and behavioral phenomena but fundamentally involves emotional learning that is best accounted for by conditioning principles. Anxiety, an anticipatory emotional state that functions to prepare the individual for the next panic, is different from panic, an emotional state designed to deal with a traumatic event that is already in progress. However, the presence of conditioned anxiety potentiates the next panic, which begins the individual’s spiral into Panic Disorder. In the client’s case as well, his exposure to situations in which he experienced the heightened bodily symptoms became associated with the thinking pattern that he was going to have a panic attack. In future instances, the conditioned bodily symptoms, thus lead to the triggering effect of thoughts and misinterpretations, eventually leading to a panic attack.

According to the vicious cycle model of David Clark (1986) panic attacks result from catastrophic misinterpretations of bodily or mental events. The events are misinterpreted as a sign of immediate impending disaster such as a sign of having a heart attack or collapsing or going crazy. The vicious cycle contains three elements; emotional reactions, bodily sensations and thoughts about sensations (misinterpretation). These elements are linked in a sequence which follows a particular pattern which can begin with anyone of the elements. Misinterpretation of bodily sensations is associated with anxiety and anxiety becomes a precipitating factor for another panic attack. This could be correlated with the present case as palpitations were seen as a sign of heart attack. The misinterpretation caused anxiety and maintained the vicious cycle.

 Idiosyncratic Case Conceptualization (Clark, 1986)

Management Plan

The client’s symptoms were managed and treated under the lines of Cognitive Behavior Therapy.

Short-Term Goals

Short-term goals Therapeutically Applied Techniques
To build trust and understanding between the therapist and client Therapeutic Alliance

Supportive work

To provide information to the client and his mother about his symptoms, their etiology, prevalence, treatment options, prognosis and client’s role Collaborative Empiricism

Psycho-education

To make the client understand the precipitating and maintaining factors of his symptoms Socialization with the CBT model

Paired association task

Body focus task

To disconfirm the client’s misinterpretations of his symptoms and break the feedback cycle which blocks disconfirmation Behavioral reattribution strategies (Hyperventilation provocation task, Physical exercise tasks)
To modify client’s beliefs and misinterpretations Verbal reattribution strategies (Questioning the evidence, education and exploring Counter-evidence)
Normalize the client’s experience of physical symptoms Survey technique
Reduce the likelihood of relapse Relapse Prevention

Therapy Blueprint

Session Reports/ Management Plan

Session No.1                                     Time of session: 45 minutes

Session Agenda

Develop therapeutic alliance, History taking, Mental Status Examination, Symptom elicitation and subjective ratings

Techniques

History taking

Rationale: To take the client’s consent for therapy and gather information about the client’s past life, and development of symptoms. Procedure: The interview was held with the client and his mother. They were told to report the details. More relevant and in-depth information was probed by the therapist herself. An informed consent was also signed by the client to ensure he was willingly taking the therapy. Outcome:  The interview gave detailed information about identifying data, personal life, education, sexual history, pre-morbid personality and history of present illness. The interview was beneficial in obtaining information of client’s symptoms, duration and frequency of symptoms, etiological factors as well as the maintaining factors. History was elicited to gain knowledge about the client’s daily life functioning before and after the emergence of symptoms. Family history was elicited to identify the support system for the client. History was also validated from his mother who provided with more information about the client’s behavior. The interview as a whole provided information about the client’s current health.

Mental Status Examination

Rationale: To assess the client’s functioning in multiple areas.. Procedure: Some of the information was gathered by observing the client’s behavior, actions and speech while others were directly asked from the client. Outcome: The client had appropriate behavioral functioning except the presence of a pre-occupation with his bodily symptoms and reactions.

Symptoms Elicitation and Subjective Rating

Rationale: To get a clearer picture of the client’s symptoms and his own rating about each symptom. Procedure: The client was asked to rate his symptom on a scale of 0-10 where 0 was least problematic and 10 was the most. Outcome: The client prioritized his symptoms according to their severity which helped in determining which symptoms were to be dealt first.

Therapeutic Alliance

Rationale: To bring both the therapist and client at ease and on good terms, trust each other, be open towards one another and show respect. The alliance is necessary to create a sense of understanding, confidentiality and regard between both individuals so that blocks and hesitance can be avoided. Procedure: The therapist, at first, introduced herself to the client and his care-giver after which they were allowed to explain their problems. The client was shown unconditional positive regard while he was telling about his beliefs and symptoms. Empathy was practiced to ensure that the therapist understood and cared for what problems the client was going through.  Reassurance was also provided in the initial session to develop a sense of concern toward the client. During the process, the client’s mother also discussed the problems openly providing with maximum information about the client. Interruptions were kept at minimum to ensure adequate flow of information towards the therapist. Outcome: The client trusted the therapist and problems were discussed freely.

Homework given: Panic diary was given to assess the frequency, duration, intensity, antecedents of panic attacks.

Session No.2                                           Time of session: 45 minutes

Session Agenda

Continuation and completion of history, Differential diagnoses, formal assessment (Panic rating scale)

Homework review: The client’s panic diary was reviewed.

Techniques

Continuation and Completion of history

Rationale: To obtain more detailed information about specific areas of client’s life.  Procedure: The client was asked to report more information which he may have missed in the last session. Moreover, the therapist also inquired more information which she previously could not ask. Outcome: Revisiting the history helped in filling the gaps and getting a more detailed analysis of the problems

Differential Diagnoses (American Psychological Association, 2013)

Rationale: To get a clearer picture of the client’s symptoms and rule out irrelevant diagnosis. Procedure: Symptoms specific to the disorder were asked. The cluster of anxiety disorders were thoroughly investigated to reach to a final diagnosis. Outcome: PTSD and specific phobia were ruled out while Panic disorder was the most justified.

Formal assessment (Panic rating scale) (Wells, 1997)

Rationale: To confirm the presence of panic attacks and consequent coping strategies. Procedure: Panic rating scale was self-administered by the client in duration of 10 minutes. Outcome:  There was a high frequency of panic attacks experienced by the client and multiple coping strategies were employed by him to cope with the symptoms

Homework given: Panic diary was given again to be filled thoroughly.

Session No.3                                               Time of session: 45 minutes

Session Agenda

Psycho-education, socialization, paired association task, body focus task

Review of previous session: The previous session was reviewed by summarizing the client’s symptoms and his performance on the questionnaires. This helped in bridging the gap between previously told symptoms and new information which was to be provided in the present session.

Homework review: Panic diary was reviewed. Clarifications were obtained for information that were vague.

Techniques

Psycho-education (Wells, 1997)

Rationale: To orient the client towards his symptoms, their development, precipitating factors, treatment plan and prognosis.  Procedure: Psycho-education was conducted to address queries of the client about the illness i.e. what it is. why was it happening, what other symptoms could emerge, what should be the measures taken, are medicines necessary, what can be the psychological treatment plans, how long will the client take to recover and what is the probability of complete eliminations of symptoms. The information was provided under the light of recent researches and the diagnostic statistical manual. The process of psycho-education was also accompanied by informing the client about what was required from him. The role of the therapist was clarified and client was told to help himself at maximum. Therapy protocol was discussed i.e. the no. of sessions, duration of sessions and expectations of the client from the therapist. Importance of homework assignments was also discussed. Outcome: . It helped to broaden the insight if client regarding his symptoms.

Socialization (Wells, 1997)

Rationale: To make the client understand the development and process of his disorder. Procedure: The client was explained the CBT model of Panic disorder to make him know how the problems develop and form a vicious cycle. The precipitating and maintaining factors of panic attacks were also elaborated so that he would understand the dimensions of his problem and recognize the points of treatment. Idiosyncratic examples of bodily symptoms experienced by the client were illustrated during the session, interpretation, and avoidance behaviors were put into the model for more clarification. Outcome: The client was initially reluctant in accepting that exacerbation of his symptoms were due to his thinking patterns but the model was revised after reattribution strategies, and at that point he agreed with the model and understood it adequately

Paired association task (Wells, 1997)

Rationale: To orient the client towards the underlying mechanism of his cognitions. Procedure: It was executed in which he was given pair of words in which one minor symptom was associated with another extreme bodily condition, for example, increased heart rate with heart attack, inability to breathe with suffocation etc. The task was presented by asking the client to read the pair of words out loud without explaining the rationale. Within 10-15 seconds, the client had furrows on his forehead and was looking anxious. A whole minute of reading the pairs caused him to get more fearful and he started breathing heavily. The words were then removed and the client was asked what he interpreted from the activity. Outcome: He got some understanding of its purpose which was then further explained by the therapist. He was clarified that the more he misinterpreted his symptoms, more he was prone to exacerbate them. He clearly understood this technique that beliefs of catastrophe exacerbate anxiety.

Body-Focus Task (Wells, 1997)

Rationale: To elaborate the phenomenon of selective attention and misperception. Procedure: The client was asked to focus on the palm of his hand and in second time his face for 3 minutes. He was given a mirror and was asked to look closely to all aspects of his face or hand. After the time had elapsed he was asked about the things he noticed. His response showed that he had noticed more negative features on his face. This point was then taken by the therapist to explain to him how constant monitoring of oneself can cause distortions in perception and focus on unreal aspects of the situation. He was given his own example that when he repeatedly checked his pulse and heartbeat, he mostly misperceived them which made him more concerned. Outcome: The task was helpful in making the client understand the consequences of his behavior and how they contributed towards the vicious cycle of thinking and avoiding.

Homework given: To practice body-focus task again at home. Read and understand the CBT model in detail

Session No.4                                                                                       Time of session: 45 minutes

Session Agenda

Psyho-education revised, Disconfirming client’s beliefs and reassurances, normalizing

Homework review: The client was asked if he felt convinced about overemphasis and selective attention. He reported that he did those tasks and noticed that the things which were focused more proved to have more negativity in them.

Techniques

Psycho-education revised

Rationale: To relieve the client’s stress about duration of symptoms and treatment. Procedure: The client kept on asking how long the symptoms will take to subside. He was again educated about his own role in decreasing the symptoms and improving his health. The factors that contributed towards a better prognosis were discussed. The importance of treatment adherence was emphasized and role of medicines was also clarified. Outcome: The client felt relieved after hearing that the symptoms can also go away completely. He also agreed to work upon his health with dedication.

Disconfirmation of beliefs

Rationale: To decrease the client’s reliance on irrelevant material on the Internet and consider the doctor’s and therapist’s words more competent. Procedure: Many examples about information from the Internet that misled people were discussed and the authenticity of information present on online websites was explicitly explained. He was convinced that guidance given by professionals on a one-to-on e basis is more beneficial than random facts and figures on the Internet. Outcome: The client seemed convinced by the discussion and decided that he will not draw conclusions by reading information on the Internet.

Mini-survey (Wells, 1997)

Rationale: To normalize the client about the existence of same symptoms in all individuals. Procedure: The client was taken to 5 people who were interviewed if they felt some of the symptoms felt by the client himself. They were also asked about the situations in which they felt such symptoms and how they coped with them. The client was allowed to question the people in detail to remove any ambiguities. Outcome: He understood that people also experience the same symptoms either at different times or all at the same time but their reasoning and attributions are different from those of the client.

Homework given: To continue physical activities and keep a check on the other reasons those are causing physical symptoms to occur rather than the probability of worse health consequences.

Session No.5                                              Time of session: 45 minutes

Session Agenda

Behavioral Reattribution tasks (Hyperventilation provocation task, Physical exercise)

Homework review: The client was asked about his progress in refraining from reassurance and how his family responded to the survey technique. He reported that all the members felt those symptoms but nothing happened to them neither did they stress over those signs.

Techniques

Hyperventilation provocation task (Wells, 1997)

Rationale: To induce panicogenic sensations in the client which were then related to disconfirm client’s beliefs. Procedure: The client was asked to walk on the lines of the tiles and breathe heavily. The activities helped in inducing symptoms such as increased heartbeat, sweating and dizziness in the client. After 2 minutes of heavy breathing the client was asked about his beliefs. His beliefs were then challenged as he induced the symptoms himself and nothing further happened. Outcome: His previous beliefs of dying or getting a heart attack were thus disconfirmed.

Physical Exercise tasks (Wells, 1997)

Rationale: As the client used to avoid strenuous activities so his heartbeat would remain stable, physical exercise was done to disconfirm beliefs. Procedure: The task was introduced by making the client run up and down the stairs outside the session room where the environment was congested. The client repeatedly stopped in between as he thought that he would have a heart attack but he was made to do it for another minute. He checked his heartbeat and pulse from time to time but he was explained by the therapist how it is least likely to have a heart attack just on the basis of the present symptoms. Outcome: At the end he was convinced that he would not die and nothing would happen to him rather his symptoms had many other reasons.

Homework given: To continue doing some physical exercise and record the times he felt the symptoms but nothing further happened.

Session No.6                                              Time of session: 45 minutes

Session Agenda

Verbal Reattribution (Education about adrenaline rush), Decreasing avoidance (Using metaphors)

Homework review: The client did some physical activity which he reported during the session. The activities were utilized to disconfirm the client’s beliefs.

Techniques

Education about adrenaline rush (Wells, 1997)

Rationale: To educate the client regarding the multiple factors that may be attributed for his physical symptoms. To make him reattribute his symptoms to other, more relevant and plausible factors. Procedure: The client was told about the adrenaline rush in which there is increased hormonal flow when the individual gets excited. In addition, he was also told why heart rate increases during stress and how one could not get faint when the heart was beating faster. He was also given counterevidence from his own situations and then related with the empirical basis for more conceptual clarity. Outcome: The research based evidence proved to be a significant factor which reduced the client’s intensity of beliefs.

Decreasing avoidance behaviors (Wells, 1997)

Rationale: To make the client realize the consequences of his avoidance behaviors and how they were helping in strengthening the client’s beliefs. Procedure: The client was given multiple examples, analogies and metaphors which suggested that people who tend to avoid certain circumstances end up in a cycle where they are never exposed to counter evidences. The prophecy keeps on fulfilling itself rather than the disconfirmation of his/her belief. Outcome: He understood the irony in those examples and realized that until he would quit his avoidance behaviors he will never know what happens in those situations.

Homework given: The client was asked to restrict his avoidance behaviors such as drinking water, checking heartbeat, asking someone to check blood pressure rather stay in the situation and observe what happens.

Session No.7                                             Time of session: 45 minutes

Session Agenda

Verbal Reattribution (Questioning the evidence/counter evidence and questioning the mechanism)

Homework review: The client was asked about the times he felt the symptoms and what other factors were responsible in causing them. He reported that many times he felt the symptoms after eating food or climbing the stairs or when he was watching a stressful video. His own observations helped in shaking his beliefs.

Techniques

Questioning the evidence (Verbal Reattribution) (Wells, 1997)

Rationale: To make the client identify evidence and counter evidence of thought in order to disconfirm his beliefs. Procedure: The client was asked to write down the evidences he had that a panic attack would occur or that he would die because of his symptoms. He listed down his symptoms that made him think that he had a heart condition and it may prove fatal. On the other hand he listed down counter evidences for all the past times he experienced a panic attack but nothing happened and also about future events. Outcome: It was evident from the list that there was less evidence about a panic attack to occur or an accident to happen. This made the client realized that the probability of a panic attack to occur was majorly in his head rather than a fact.

Questioning the mechanism (Wells, 1997)

Rationale: To educate the client and bring into awareness the actual mechanisms of his fears and the discrepancy between actual and perceived threat. Procedure: He was first inquired if he knew how heart attack or fatal diseases were acquired and what mechanisms were operative in these conditions. After his reporting, he was briefed about the actual processes that were involved in making an individual prone towards heart conditions or medical diseases (genetic factors, dietary habits, abnormal blood tests etc.). Outcome: The technique was helpful in educating the client as he was eager to know the true reasons of such diseases and felt relieved that he had none.

Coping Cards

Rationale: To make the client give positive self-instructions and us them in the time of anxiety. Procedure: The client was given 5” by 5” cards on which coping statements such as ‘I am OK’,’ I am physically fit’, ‘I can handle the symptoms’, ‘The symptoms may be due to some other reasons’ were written. He was asked to keep the cards with him or attach near his working table so that he can use them whenever he experienced his symptoms. Outcome: The cards helped in reminding the techniques he had learnt in therapy and giving positive feedback to himself. They also helped the client to tackle anxious situation by staying in them rather than avoiding.

Homework given: He was asked to work on his cognitions whenever he thoughts about his symptoms or future panic attacks. He was asked to analyze evidences in his mind and disconfirm his beliefs by the techniques learnt during session.  Moreover the coping cards were also given to practice when he faced stressful situations.

Session No.8                                                   Time of session: 45 minutes

Session Agenda

Relapse prevention, therapy blueprint, post-assessment

Homework review: The client reported that he used the strategies that were taught to him and they were helpful in subsiding the symptoms. Coping strategies were employed by the client by memorizing and using them during strenuous activity.

Techniques

Relapse Prevention and Therapy Blueprint

Rationale: To aid the client in future situations, in case of any relapse. Procedure: After the client was gone through all the techniques and he had practiced them at home, he was again explained all the techniques in one session and how it had helped him in dealing with the symptoms. He was given a therapy blueprint which summarized the major techniques done, situations in which that technique could be applied and its procedure.

Post-assessment

Visual Analogue

Table 6: Pre and Post-treatment Ratings of the Symptoms According to the Client

Symptoms Pre-treatment Ratings (0-10) Post-treatment Rating (0-10)
Increased Heart rate, sweating, dizziness, breathlessness, numbness 10 3
Fear of having a heart attack 9 3
Fear of losing control 9 2
Fear of dying 9 2
Fear of having a panic attack in the future. 9 4

Panic Rating Scale

Table 7: Pre and Post assessment of the Panic Rating Scale

Item # Statement Pre-Treatment Rating Post-Treatment Rating
1 Number of panic attacks in the last week 10 2
2 Frequency of avoidance behaviors 7-8 times 2-3 times
3 Average rating of coping strategies 60% on average 2/8 on average
4 Average rating of beliefs on anxious thoughts 45% on average 20% on average

Outcome of therapy

There was a decline in client’s symptoms as assessed by the pre and post assessment. He reported that he was feeling better and his panic attacks were greatly reduced. He utilized the technique taught during therapy which helped him distinctly.

Limitations and Suggestions

The client had to leave for Dubai after his 8th session hence more follow-up sessions could not be conducted. He was suggested to consult a psychologist for a follow-up session.

References;
  • American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. Fourth Edition, Revised
  • Bouton, M. E., Mineka, S., & Barlow, D. H. (2001). A modern learning theory perspective on the etiology of panic disorder. Psychological review, 108(1), 4.
  • Clark DM. A cognitive approach to panic. Behav Res Ther 1986; 24 :461–70.
  • Goldstein, A. J., & Chambless, D. L. (1978). A reanalysis of agoraphobia. Behavior Therapy, 9(1), 47-59.
  • Wells, A. and Papageorgiou, C. (2004). Depressive Rumination: Nature, Theory and Treatment. UK: John Wiley & Sons, Ltd.

 

Case 3

Case Summary

            The client was a 40 year old woman, educated up to B.A. and belonged to lower middle socio economic status. The client was referred to the trainee clinical psychologist for the assessment and management of her symptoms. Her primary complaints included repetitive, intrusive thoughts and associated repetitive behaviors, anxiety due to thoughts and disturbance in personal and social life. She was informally assessed by a clinical and diagnostic interview, mental status examination, subjective ratings and baseline for obsessions and compulsions and Y-BOCS. Based on the history and assessment she was diagnosed with Obsessive Compulsive Disorder. Her management plan was devised on the basis of Cognitive Behavior therapy encompassing techniques such as socialization, questioning evidence and mechanism, survey method, cost-benefit analysis, exposure and response prevention and concentration exercises. The techniques and willingness of the client helped in eliminating the client’s symptoms to a considerable degree.

Bio Data

Name: K.S.

Age: 40 years

Gender: Female

Education: B.A.

No. of Siblings: 4 (2 sisters, 1 brother)

Birth order: Third born

Marital Status: Married

No. of Children: 4

Religion: Islam

Informant: Husband, Client Herself

Reason and Source of Referral

The client came to the Centre for Clinical Psychology with the complaints of repetitive and intrusive thoughts of being dirty resulting in excessive hand washing, clothes, cleaning house floor and washrooms. The symptoms also included distress due to her cleanliness behaviors, frustration, low mood, decreased social interaction and disturbance in her personal and social life. She came to the Centre upon the recommendation of her husband’s friend. She was referred to a trainee clinical psychologist for the assessment and management of her symptoms.

Presenting Complaints

Table 1: Complaints of Patient as reported by herself

Duration Complaints
From 1-3 years I wash my hands a lot. I am not satisfied even after washing, so I wash again
From 2 years I wash clothes all day so everyone is clean
From 2 years It always seems that i am impure
From 2 years The ground looks dirty so I wash it again and again
From 2 years I often have a feeling of urination and I change my clothes 3 to 4 times a day
From 2 years Don’t watch tv. Looks like pajama will be dirty after that
From 2 years I keep scolding the children to take care of cleanliness
From 1 year I’m worried about what happened to me. Everyone is upset because of me.
From 1 year I have reduced meeting with people because I don’t think they care about cleanliness
From 1 year Looks like I won’t be fine. There is no solution to my problems
From 1 year Laughter does not make the heart. I live in myself all the time. The mood is extinguished
From 1 year The house is not functioning properly. There is no courage. There is pain in the muscles of the body all the time

 History of Present Illness

The client’s problems started to emerge after a disturbing event occurred in her life in 2014. The client and her family lived in an underdeveloped area where most of the houses were congested and close. Her own house was not built properly so she and her husband agreed to renovate the house. Her husband called upon 3 laborers who were allowed to do plumbing and improve the sanitary lines of the house. The client used to remain home while her husband went to work and all her children would go to school. During the time of renovation, she started noticing the activities of the laborers. The laborers would usually make the house floor dirty with cement, dirt and garbage. The client reported that they would also urinate in the same area as there wasn’t another washroom in the house. They ate with the same hands and in the same place. The dirt did not disturb the client as much as the uncleanliness (Na’paaki) caused by those laborers. She started commanding the laborers to keep the area tidy and do their work with cleanliness. The laborers usually did not comply with the client’s commands so the client herself started to clean the area every day after the laborers left. The client’s husband told her not to clean it as the house would get dirty again the next day, but she felt uneasy so went forward with her own decision. It was then that the client started forming linkages between what was dirty and what became dirty after contact.

From then on, I started noticing what was touching. I used to see that if a child went to a dirty place and then brought his feet on the clean floor, he would tell him to wash his feet. Then if someone came from there and sat on the sofa, she would clean the sofa

The laborers completed their work in approximately 2 weeks after which the client had to clean the house entirely on her own. She found feces in some places which made her extremely angry and upset. She still cleaned the house as properly as she could. It was after then that the client’s symptoms started to emerge. She never got satisfied with the hygiene conditions of the house. She washed the house floor numerously with multiple detergents and also started to make rules for her children to enter the house. She kept an extra pair of shoes outside the house for herself and bought soaps of different companies to keep in the lavatory.

Within a year (2015), the client’s problem exacerbated greatly. She washed her hands innumerably throughout the day and always remained doubtful if she had washed them. She asked children to keep themselves tidy and not to sit on the sofas or chairs if they had not changed their clothes. She made a separate place for her religious activities (Namaz and Quran).

In late 2015, the client’s daughter started menstruating which further increased the client’s symptoms. She would repeatedly tell her daughter to take bath, change clothes, not to sit on something higher rather on the floor and to keep herself away from others. She separated her daughter’s towels, cupboards during her menstruation days. She also washed her daughter’s clothes separately so that the other clothes may not get “Na-paak”. This made her relationship with her daughter distant and the client started to become angry and irritable more often. She noticed every move of her daughter and linked each move with the previous one. This made her think that where ever her daughter sat was then ‘Na-paak’ and she had to wash the place and clothes. Her frequency of washing clothes increased greatly. She started buying large packets of surf and detergents and washed clothes every day for up to 5-6 hours. She would herself change clothes repeatedly which increased up to 6-7 dresses a day in the following year.

In 2016, the client’s husband noticed changes in her behavior and attitude and saw that the client was becoming asocial. She stopped visiting her sister or her mother and did not leave the house except for something that was very important. She kept an ‘abaya’ which she wore whenever she went outside and changed it as soon as she came back to the house. The client started to remain indoors, did not dress up or get ready besides her husband’s wishes and tried to remain isolated from others. She spent most of her time washing clothes or dishes and keeping the house neat and tidy. The strenuous activity made the client tired after the whole day and she would experience frequent body aches.  She started to remain distressed about her health as she realized that she was pushing herself beyond the limit but could not control herself. She considered her husband strict so did not share her problems with him as well. She tried to perform all her duties but her health would occasionally put her down. She also felt helpless about her condition stating,

‘One of my sisters has cancer. When I see him taking medicine, I am jealous that he has the solution to his problems but I don’t have it.

The client’s husband became concerned about her health and sought advice from his colleagues at work. They recommended a psychiatrist and a psychologist but the client was reluctant to visit any doctor as she thought that there was no cure for it. After insistence of her husband, she decided to visit a psychiatrist in a nearby hospital who told her to see a psychologist. She then came to the Centre for Clinical Psychology with the complaints of repetitive and intrusive thoughts of being dirty resulting in excessive hand washing, clothes, cleaning house floor and washrooms. The symptoms also included distress due to her cleanliness behaviors, frustration, low mood, decreased social interaction and disturbance in her personal and social life.

Background History

Family History

Father. The client’s father died at the age of 63 years due to stroke. He was diagnosed with hypertension, diabetes and risk of cardiovascular diseases. He took his medicines regularly but still suffered from a fatal heart attack. He did not have any psychological problems. He was an extremely strict person, remained angry most of the time, was short-tempered, had few social interactions and remained to himself according to the client’s account. The client’s relationship with her father was distant as she never felt comfortable talking to him. Her father did not interact with any of his children from their childhood and used to remain busy in his work. He rarely expressed his love or care for the children. The client reported that she spent most of the childhood remaining scared from her father. Besides the uncongenial relationship, the client still felt sad on her father’s sudden death and occasionally missed and prayed for him.

Mother. The client’s mother was 68 years old suffering from a cataract and heart problems. She took anxiolytics to help her sleep but did not have any significant psychological issues. According to the client, her mother was also strict and had perfectionistic tendencies. The client had some attachment with her mother but still did not feel emotionally linked to her. Her childhood was also filled with her mother’s orders and restriction regarding leaving the house, meeting people, keeping oneself clean and religious obligations. Although the client learned a lot but she did not share her issues with her mother. She used to visit her mother once a week but since the client’s symptoms started appearing she distanced herself from everyone including her mother.

First born sister. The client’s sister was in her forties, was educated up to F.A. and was a housewife. She was married to her cousin and had a contented life. She had no physical or psychological ailment. She remained concerned about her mother’s health but was mostly involved with her family matters. Her relationship with her sister was satisfactory. Both of them used to visit each other occasionally before the client’s symptoms started to emerge. The relationship got distant after the client’s issues but they still talked through phone calls. They took care of each other since childhood and so the client felt more attached to her sister than to her mother.

Second born brother. The client’s brother was 43 years old, educated up to Masters and was a private shop owner in his residential area. He suffered from hypertension. He used to smoke sometimes. The client’s relationship with her brother was distant as he adopted the same attitude exhibited by his father. He was strict in attitude and had conservative opinions about women due to which the client did not feel comfortable while conversing with her brother. She still maintained healthy relationship with his wife by calling her and keeping in touch with their issues. She mentioned that her brother was present for her in the time of need.

Third born was the client herself.

Fourth born sister. The client’s younger sister was in her thirties, was married and a housewife. She had three children and was satisfied at home. She was suffering from breast cancer but was getting her treatment done through surgery and chemotherapy. According to the client, she was a cheerful person who sometimes remained concerned about her health and children but still was social and maintained satisfactory relationships with others. The client also enjoyed being with her but they met less as she resided out of the city. They had pleasant interactions whenever they met and also remained concerned about each other’s health.

General Home Atmosphere (before marriage). The client had an extremely strict atmosphere at home. Her father was the bread winner and dominating figure at that time. She belonged to a lower middle socio economic family. The children weren’t allowed to do what they wanted where girls usually helped their mother while boys sat with their father. The client’s mother also kept a stringent attitude with all her daughters making family bonding weak. The client usually remained quiet whenever she was at home and also restricted herself from talking with the family much. All the members of the family were religious and all religious activities were carried out with discipline and respect.

Personal History

Birth and Childhood History. The client was born through normal delivery by a mid-wife at home. She had average weight at the time of birth and color was pink. There were no problems during pregnancy while the client was conceived. She achieved her developmental milestones at appropriate time. She was a quiet child but played frequently with her sisters. She received love and affection from her parents which gradually reduced when she entered adolescence due to the mindset of her parents. No neurotic traits were reported in the client’s childhood.

Educational History. The client started her education at the age of seven years. She was an above average student who liked going to school. She reported that she was punctual, social and obedient. She had satisfactory relationship with her teachers. She liked Urdu and Mathematics. Throughout her early education she remained a bright student. She passed her matriculation and intermediate with average marks as she had to do the house chores as well. Moreover, her father kept on pressurizing her to quit school and stay at home. Besides the pressure she insisted on going to university and so completed her B.A. in harsh home environment. She claimed that she missed her college and university life as she had made a lot of friends and felt independent when she was out of the house.

Pubertal History. The client achieved puberty at the age of 13 years. She was well-informed about the phenomenon by her mother before it occurred. She coped well with the changes and learned to handle it quickly. She told that her mother was specific in keeping body and house clean. The client and her sisters were extra cautious in handling their sanitary things. They had to be vigilant while going in front of the male members of the house and keeping it strictly confidential. The client handled the situation with ease and perfection besides the extensive pressure. She did not feel difficulty in maintaining cleanliness at that time.

Marital History. The client had been married since 18 years. She had an arrange marriage. Her husband was a 48 years old man who had done B. Ed. and was working as a clerk in a university. The initial years were difficult for the client as she tried to adjust with a person she barely knew. The couple had mutual understanding but the client had complaints from her husband for not giving enough time. Moreover, they also had financial issues as her husband was reluctant in giving money for house expenses. She informed that her husband had a dominant personality and so she remained submissive most of the time. Both of them still maintained a healthy bond having care, love and affection between them. Her husband remained concerned about the client’s health since the last one year. Since the symptoms emerged, the client also observed a change in his husband’s attitude and appreciated his concern. Both of them mutually decided their children’s future but her husband still had the veto power. The client’s husband sometimes showed frustration regarding her symptoms but on other times proved to be supportive as well.

The client had 4 children, 2 sons and 2 daughters. The eldest child was her son who was 17 years old and was studying in first year. The next two were her daughters. Her elder daughter was doing matriculation while the younger daughter was in 8th class. The youngest child was her son who was still in primary class. The client remained pre-occupied in upbringing her children and fulfilling all her responsibilities. She cooked, cleaned and washed for them and also performed the duty of walking them to school. Since the symptoms emerged, the client’s remained angry most of the time. She scolded them and tried to discipline them to the maximum. Her daughters grew distant from her due to her constant correction and taunts. She still helped them in their studies and remained concerned about them. One of the primary complaints of the client from her children was that they did not maintain cleanliness in the house.

Sexual History. There were no reports of any homosexual or heterosexual experience of the client before marriage. She had a satisfactory sexual life with her husband. There was mutual consent in almost all interactions. The client reported that the interactions had lessened now as she tried to avoid them as she thought that the act will make her dirty. She remained worried constantly that her clothes will get dirty due to arousal. This made her avoid watching the television or sitting close to her husband. The fears made her distant from her husband and she started to remain indulged in religious practices. Even upon the insistence of her husband, she did not get ready or dress up for her husband rather tried to remain physically away from him.

Pre-morbid Personality. Even though the client had calm and quiet personality before her symptoms emerged, she was still a social and content person. She used to meet with her relatives frequently, arranging meet-ups at her mother’s house and sitting in gatherings. She responded to stress calmly and with maturity. She had high religious inclination and maintained her social relationships. Her self-esteem and confidence was low.

Psychological Assessment

The assessment was carried out on an informal basis upon the following lines:

  • Clinical Interview
  • Mental Status Examination
  • Visual Analogue
  • Baseline for obsessions and compulsions

Clinical Interview

Initially, the client was briefed about confidentiality and therapeutic process. Consent form was signed by the client, which was followed by a detailed clinical interview with the client and her husband. All information was corroborated amongst the informants. The clinical interview comprised of information regarding the client’s familial life, personal history, pre-morbid personality etc. The interview process also included the elicitation of symptoms, their frequency, duration, intensity, maintaining and perpetuating factors. The information was used to device case formulation and management plan for the client.

Mental Status Examination

The client was an average heighted bulky woman wearing a black ‘abaya’. She had neatly done nails and her hygiene was properly maintained. She had her head and face covered but removed the veil in the session room. She sat on the chair while leaning back but her posture was hunched. She gazed towards the floor while talking and kept rubbing her hands. She refrained from touching the table corners or arms of the chair. Her tone and rate of speech was comprehendible. She appeared to have low mood and affect with irritability evident from her frowning. She reported to have frequent obsessions and compulsions. Her long-term memory was intact but she was unable to recall some short term events such as what she ate yesterday or which color clothes did she wear on the day before. She had adequate judgment and abstract thinking. Her insight regarding her problems was present.

Visual Analogue

The client was asked to rate her symptoms on a scale of 0-10 with 0 being the least problematic and 10 being the most. The scale helped in indicating which symptoms were to be prioritized and dealt first. The treatment of most intrusive symptoms also help in subsiding the lower problematic symptoms hence the rating was beneficial with respect to the treatment plan.

Table 2: Symptoms and subjective ratings of the client

Symptoms Rating (0-10)
Thoughts of uncleanliness ‘Na-paaki’ regarding clothes, house floor, sofas etc. 10
Distress due to repeated washing of hands, clothes, household items, floor etc. 10
Inability to control or suppress thoughts 10
Dissatisfaction after using the washroom, washing hands or clothes 9
Anger, frustration, irritability 9
Social withdrawal 8
Hopelessness and worry about the treatment of problems. 8
Inability to handle house chores effectively 7

Baseline for Obsessions and Compulsions

A baseline was given to the client to gain detailed information about her symptoms. The baseline incorporated minute details about the client’s obsessions such as the content of thoughts and the meaning client associated to those thoughts. Moreover the baseline also constituted information about the compulsions of the client which she did to satisfy her thoughts and the time taken in performing those compulsions. The chart also encompassed information about client’s emotional reactions and their intensities.

Table 3: Quantitative Analysis of baseline

Frequency of obsessions 25-30 times per day
Intensity of the drive to perform compulsion 9 on average
Intensity of emotions 8 on average
Duration of obsession Variable (Ranges from 1 minute to an hour)
Frequency of compulsion 5-6 times per day
Duration of compulsion Variable depending upon the compulsion (5-10 minutes in washing body parts, 30-40 minutes in bathing and 2-3 hours in washing clothes)

 

Table 4: Qualitative Analysis of baseline

Antecedent/ Triggering Event Children playing around the house

Going outside the house

Children not changing their slippers before entering the house

Going to the washroom

Visiting someone else’s place

Watching the steps and movements of others

Daughter sitting on a sofa during her menstrual cycle

Watching television

Content of obsession He had dirt on his slippers and he did not change it

My Shalwar is dirty

I did not wash my hands properly

The clothes touched the wall, now they are dirty

The floor is dirty

Others don’t keep their house clean

Interpretation of thought The place is Na’paak. I should clean it. If I won’t my prayers will be wasted. God will not accept them.
Emotions/ Affective response Agitation, Anger, Frustration, Irritability
Compulsion/Behavior Repeatedly washing hands, clothes, house floor, washroom

Making daughters wash their clothes in front of her

Keeping a constant check on the cleanliness of the house

Washing hands with two types of detergents

Refraining from leaving the house or visiting anyone else

Repeatedly washing body parts

Seeking reassurance from daughters and husband.

Formal Assessment

Yale-Brown Obsessive Compulsive Scale (Y-BOCS)

            The scale was a 10 item measure assessing he frequency of obsessions and compulsions, distress felt due to them, resisting them and control over them. Its options consisted of 0 to 4 where 0 indicated absence while 4 indicated extreme severity of the symptom. The client attempted the scale in 20 minutes.

Quantitative Analysis

Table 5: Score and level of severity of patient on items of Y-BOCS

Item Rating Level of severity
Time occupied by obsessive thoughts 3 Severe
Interference due to obsessive thoughts 3 Severe
Distress associated with obsessive thoughts 3 Severe
Resistance against obsessions 1 Mild
Degree of control over obsessive thoughts 3 Severe
Time spent performing compulsive behavior 3 Severe
Interference due to compulsive behavior 3 Severe
Distress associated with compulsive behavior 3 Severe
Resistance against compulsions 2 Moderate
Degree of control over compulsive thoughts 3 Severe

 

Table 6: Overall score of patient on Y-BOCS

Obsession sub-total Compulsion sub-total Raw score Significance
13 14 27 Severe

Qualitative Analysis

The client’s total score was 27 which fell in the category ‘severe’ indicating that her symptoms were intense and were causing disturbance in her life. She reported extreme severity in feeling distressful about her symptoms and lacking control over her obsessions. Moreover, her scores also show that she felt very little control over her compulsions and also felt extreme distress about them.

Summary of Formal and Informal Assessment

The informal assessment of the client shows the presence of frequent obsessions and the performance of compulsion in response to them. The visual analogue shows that all of the client’s symptoms were highly problematic but obsessions and compulsions were the most intrusive. The frequency, intensity and duration of the compulsions also showed disturbance in her personal and domestic life.

Diagnosis

300.3 (F42): Obsessive-Compulsive Disorder

Points in favor according to DSM-5

            The DSM-5 diagnosis of Obsessive Compulsive Disorder requires the presence of at least one of two symptoms; obsessions or compulsions. The client presents with both of them severe enough to warrant clinical attention. Obsessions were identified as being intrusive for the client which made the client feel distressful and so she tried harder to suppress the thought. The compulsions were identified as the repetitive behaviors the client did in order to relieve the anxiety provoked by obsessions. Moreover, the client spent majority of her day satisfying her obsessions thus interfering with her normal daily functioning.

Differential Diagnosis

Major Depressive Disorder: The client did not present with rumination about the past nor were her primary symptoms related to his affect. The low mood and irritability she presented with was due to the irritation and disturbance cause by her primary symptoms i.e. obsessions and compulsions. Moreover, people with MDD do not usually have compulsions so the presence of compulsions in the client points towards the diagnosis of OCD.

Obsessive Compulsive Personality Disorder: The diagnosis of OCPD requires a consistent pattern of orderliness, inflexibility, perfectionism and efficiency since the early adulthood but the client started to experience the symptoms in her late adulthood and after the incident of renovation occurred at her house. The pre-morbid personality of the client does not show any signs or symptoms such as these. Hence, the client was diagnosed with Obsessive Compulsive Disorder.

Idiosyncratic Case Conceptualization

Case Conceptualization

Case Formulation

            The client was diagnosed with Obsessive-Compulsive Disorder due to the presentation of her symptoms of repetitive, intrusive thoughts and consequently performing repetitive behaviors to relieve the anxiety cause by those thoughts. Salkoviski et. al (2001) proposed that all human beings have thoughts but when the thought become repetitive and anxiety provoking the become problematic for the person. The individual tends to blame himself for those thoughts or deliberately suppress them. The constant tug-of-war between the thought and its suppression induces negative emotions in the individual causing him to perform behaviors that tend to neutralize that anxiety. These behaviors may be mental acts or overt behavioral responses. The client also presented with the same symptoms that she had repetitive thoughts about uncleanliness. Instead of passing the thought she focused on it and was then compelled to perform the neutralizing behaviors.

Timpano et. al, (2010) studied the relationship between Obsessive-Compulsive (OC) symptoms and types of parenting. They found that OC symptoms were significantly correlated with an authoritarian parenting style. Strict parenting leads to the formation of OC beliefs that have a high ratio of personal responsibility in it and emphasizes greatly on the importance of thought. When these beliefs are triggered they cause OC symptoms. The OC beliefs thus act as mediators between parenting style and OC symptoms. The present client also had strict parents, stringent childhood and conservative upbringing. This formed OC beliefs in her that everything that comes in her mind is because of her and every bad thought is a sin. As her family was religious as well, the concept of sin and punishment was embedded in her belief system making her more prone towards developing OC symptoms.

Rachman (1997) proposed that OCD symptoms usually develop due to the meaning associated with their thought rather than the thoughts alone. This means that the individual has the power to interpret his/her thoughts constructively or in a negative manner. The people who attach negative connotations with the thought content get stuck in a cycle of thinking, interpreting, suppressing and neutralizing. This cycle then forms an OCD cycle which has both obsessions and compulsions driving it. The client was also stuck in the same process where the thought of dirtiness meant that the place was ‘Na-paak’ and it was a sin not to keep cleanliness in the house. The extreme meaning attached to the thoughts then resulted in distress and further, compulsions.

It has been studied that patients with Obsessive-Compulsive Disorder usually have an attentional bias and they are hyper vigilant towards the cues. The cues that were commonly found were repeated checking for contamination and washing.  Scholars found that OCD patients responded more quickly and specifically to OCD relevant cues e.g. a dirty toilet, broken door etc.  (Moritz, Muhlenen, Randjbar & Fricke, 2009; Tata, Liebowitz, Prunty, Cameron &Pickering, 1996). The present client also presented with an attentional bias where she mostly focused on the cleanliness of the house and would notice everyone’s behavior precisely. She would form linkages in every individual’s behavior by focusing on what the person touched first and later. The hyper vigilance and faulty interpretation caused her to react with distress towards her intrusive thoughts.

Management Plan

Short-Term Goals
Short-Term Objectives Therapeutically Applied Techniques
To develop a sound therapeutic alliance with the client Active listening, Unconditional positive regard, Reflecting on client’s words, empathy
To provide the client with information regarding her diagnosis and treatment Psycho-education

Normalization

To make the client aware with her symptoms and their formation Socialization with the CBT model, Suppression Experiments, Worry postponement experiments
To deal with intrusive thoughts i.e. obsessions Detached mindfulness

Questioning the evidence and counter evidence

Questioning the mechanism

Cost-benefit analysis

To deal with behavioral responses i.e. compulsions Exposure and response prevention

Mini-survey about normal/distressing thoughts

Disconfirmatory maneuvers

Improving the quality of life and restoring pre-morbid level of functioning Activity scheduling
To relieve fatigue and body aches Progressive muscle relaxation
Increasing client’s concentration and decreasing doubts regarding the execution of her actions Concentration exercise combined with detached mindfulness, doubt reduction techniques
Relapse prevention Therapy Blueprint
Long Term Goals
  • Follow up sessions to increase therapeutic compliance and to assess the presence of symptom substitution.
  • Continuation of short-term goals
  • Increase in social activities and improvement in quality of relationships

Session Reports/ Management Plan

Session No.1                                              Time of session: 45 minutes

Session Agenda

Develop therapeutic alliance, History taking, Mental Status Examination, Symptom elicitation and subjective ratings

Techniques

Therapeutic Alliance

Rationale: To develop a trustworthy and sound relationship between the client and the therapist. Procedure: Therapeutic alliance was developed active listening by giving the client ample time to express herself and her problems. Unconditional positive regard was practiced by being non-judgmental about the client’s views, underlying issues and intents. Empathy was provided by projecting an understanding view of the therapist and that the client’s problems were being recognized. Outcome: This encouraged the client to open up. . It helped to effectively engage the client in therapy.

History taking

Rationale: To obtain a comprehensive account of the development of client’s problems, its predisposing, maintaining and precipitating factors. Procedure: Informed consent was obtained from the client. Information about the client’s symptoms, their intensity and presenting situations were elicited. Moreover, client’s support system, social functioning, familial life and personal views were also obtained in the history Outcome: The client elaborately discussed all her life domains and cooperated with the client in giving every piece of information.

Mental Status Examination

Rationale: To assess the client’s current level of functioning and physical appearance. Procedure: The therapist observed several of the areas herself such as grooming, eye contact, posture, gait, speech etc. While some questions were directly asked from the client i.e. questions about cognitive functioning, mood, insight etc. Outcome: Obsessions and compulsions were the most significant information obtained from the examination.

Symptoms Elicitation and Subjective Rating

Rationale: To understand the client’s problems, elicit disorder specific symptoms and obtain a subjective rating of each symptom. Procedure: The client was asked to tell about the symptoms she experienced while the therapist tracked down the relevant and specific details. Moreover, the client rated her symptoms on a scale of 0-10. Outcome: The procedure helped in identifying the specific severity of each symptoms and helped in prioritizing them for treatment.

Homework given: Dysfunctional thought record and chart for obsessions and compulsions

Session No.2                                         Time of session: 45 minutes

Session Agenda

History taking (continued), Validation of history from husband, differential diagnoses, formal assessment (Y-BOCS)

Review of previous session: The client herself came up with information which she forgot to tell in the previous session.

Homework review: She did not fill the DTR or compulsions chart

Techniques

History taking (continued)

Rationale: To fill in the gaps in the history and obtain more information about past life. Procedure: Elaboration was requested from the client on few matters regarding her symptoms, symptom substitution and relationships. Outcome: More information was gained that helped in understanding the client’s disorder and the maintaining and precipitating factors.

Validation of history from husband

Rationale: To cross-check the client’s account with her husband’s verbatim. Procedure: The therapist separately interviewed the client’s husband with the consent of the client and inquired about the problems. a joint interview was also held afterwards which helped in synchronizing the complaints. Outcome: There were slight differences in the client’s verdict and husband’s verdict which were resolved in the joint session.

Differential Diagnoses (American Psychological Association, 2013)

Rationale: To get a clearer picture of the client’s symptoms and rule out irrelevant diagnosis. Procedure. She was asked to clarify some of the symptoms, while symptoms from other disorders were ruled out. Specific symptoms of OCD were elicited more. Outcome: The differentials helped in confirming the diagnosis of OCD and ruling out GAD or Depression.

Formal assessment

Rationale: To corroborate informal assessment with standardized and developed questionnaires. Procedure: Y-BOCS was administered collaboratively by the client and therapist. The statements not understood by the client were clarified. It took the client 30 minutes to complete the test. Outcome:  The instrument helped in obtaining a qualitative analysis of the client’s symptoms.

Homework given: Dysfunctional thought record and chart for obsessions and compulsions were given again and client was briefed about cooperative and treatment adherence.

Session No.3                                                Time of session: 45 minutes

Session Agenda

Psycho-education, Activity Scheduling

Review of previous session: The client trusted the therapist and felt comforted and understood after the previous session

Homework review: The client filled the DTR and obsessions chart. Gaps in the chart were filled during the session.

Techniques

Psycho-education (Wells, 1997)

Rationale: To orient the client towards her symptoms, their development, precipitating factors, treatment plan and prognosis.  Procedure: The client and her husband were educated about the client’s disorder in detail. The psycho-education comprised of Obsessive-Compulsive Disorder, the causes of development of symptoms, its modes of treatment (medical and psychological) and prognostic factors. Normalization involved the provision of information about the incidence and prevalence of the disorder in indigenous population and their recovery rates. Moreover, the client was also briefed about the therapeutic process, length and duration of sessions, role of the psychologist and client herself and the duration in which the effectiveness of treatment will reveal itself. Outcome: This information gave hope to the client about the effectiveness of treatment as she previously thought that there was no cure for her symptoms and she will have to live in the same way throughout her life. The purpose of the therapy was also provided in order to instill internal locus of control.

Psycho-education (Development of symptoms)

Rationale: To make the client understand the process and functioning of her symptoms. To help to educate the client about the intervention point in the cycle. Procedure: The client was socialized with the CBT model by first explaining her each step in Rachman’s OCD cycle. The simple version of the cycle was helpful in educating the client about obsessions and compulsions and where the cycle had to be broken. After the client had occupied an understanding of how both processes operated, the Wells and Mathews model was explained. The client was then encouraged to put her own examples in the model making it idiosyncratically specific. She identified her thought and behaviors readily, but the therapist had to explain the in between process of meta-beliefs and appraisals regarding intrusions. She was explained about the importance of the meaning she attached to her thoughts and how those meanings led to the development of the symptoms. Outcome: Initially, it was difficult for the client to accept the model but various examples from her own life helped to make it simpler and understandable for her.

Activity Scheduling

Rationale: To make the client indulge in productive activities rather than ruminating over her thoughts and to restore the client’s pre-morbid level of functioning. To make her concentrate on other people and other tasks rather than just washing or cleaning. Procedure. In order to introduce distractions and a healthier social life, she was asked to bring groceries for her house and visit her mother or sister twice a week. Outcome: The client agreed to follow the schedule assigned which helped her greatly as she liked visiting her sister. She also felt that she was performing her religious obligation of visiting her mother through this process. The techniques increased her outgoing behaviors and also got her to keep herself maintained and fresh.

Homework given: To complete the tasks given in activity schedule. She was also given the CBT model to read it again daily until the next session.

Session No.4                               Time of session: 45 minutes

Session Agenda

Revisiting psycho-education, thought-suppression experiments, worry postponement

Review of previous session: The previous session was thoroughly reviewed to summarize the information given to the client which she received in the last session. The therapist briefly provided with the psycho-education again and also emphasized to follow the activity schedule completely.

Homework review: She follow the activity schedule up to 50% as she could not visit her sister’s or mother’s house during the week. But she took time out to do the groceries and also managed to read the CBT model of OCD almost daily.

Techniques

Worry-postponement experiment (Wells, 1997)

Rationale: To make the client realize that worrying is in her own control and that she can shut it off whenever she desires. Procedure: She was asked about the times she was really busy and what thoughts occupied her time when she was busy in a particular task. Then she was asked to identify her thoughts when she lied down and was alone. The client’s distressing thoughts mostly occupied her time when she was alone. The thoughts did not occur to her in busy times such as when talking to someone, sitting in a group of people, indulged in cooking etc. Outcome: The procedure was helpful by making the client understand that she was in control all the time. She understood that she could switch the button off whenever she wanted so the thoughts would go away.

Thought-suppression experiments (Wells, 1997)

Rationale: to explain to her that the more she tried to get rid of the thoughts, the more they would re-occur in her mind. Procedure: She was initially asked to think about a blue rabbit for 1 minute. After that, she was asked to stop thinking about the blue rabbit for 1 minute and not let the thought of the rabbit come in her mind again. She was unable to do so which fulfilled the purpose of the experiment. She was then briefed about the rationale of the technique and how it applied to her intrusive thoughts as well. Outcome: The client understood the technique and its rationale. She also realized that only distraction is not the solution to the problems.

Homework given: To complete the tasks given in activity scheduling and try both thought suppression experiment and worry postponement experiment at home. She was also asked to identify half an hour as the worry time when she can sit and think about the distressing thoughts.

Session No.5                                                Time of session: 45 minutes

Session Agenda

Verbal Reattribution by normalizing thoughts/worries (concept of mindfulness) and mini survey

Homework review: The client was able to follow the activity schedule completely. She felt happy after visiting her family. She reported that it was unable for her to deliberately bring the distressful thoughts in her mind during the worry-time specified. After practicing the experiments at home, she was also convinced that her worry was in her own control

Techniques

Normalizing thoughts/worries (concept of mindfulness) (Wells, 1997)

Rationale: To make the client realize the importance of remaining in the present was told along with the effectiveness of viewing situation objectively. Procedure: The client was explained through various exemplifications that thoughts are a person’s own creation and every individual has a different thought about the same situation. So the client was encouraged to see every trigger as a particular situation which she would view without letting her own beliefs and biases come in between. Additionally, she was also explained that an individual comes across hundreds of thoughts during the day but the thoughts on which he focuses will be the ones that would create distress. So the concept and a thought coming and letting it pass by without letting it intrude in the client’s daily functioning was proposed. Outcome: Through repetitive explanations and examples during the session, the client was able to grasp the concept and take control over her thoughts. The information that everyone comes by these thoughts but does not stress over them, significantly clicked the client and helped to convince over the normality of thoughts.

Mini-survey (Wells, 1997)

Rationale: To provide the client with evidence about normal thoughts and distressing thoughts. Procedure: A column was made in which 5 people were listed down and each person was asked about the specific thoughts that the client experienced (thoughts of Na-paaki, uncleanliness). They were then inquired if they felt distressed after those thoughts or did any behaviors or actions to reverse the thought. The frequency of thoughts and related behaviors were listed down. Some people were also asked about the interpretation they gave to their thoughts. Outcome: The client felt somewhat relieved that the thoughts are a normal process but the meaning one attaches to them and the neutralizing behaviors are the point that is problematic.

Homework given: To conduct a mini-survey at home as well and to practice mindfulness by focusing on the present and try to let go of thoughts.

Session No.6                                               Time of session: 1 hour

Session Agenda

Introduction to Exposure and Response Prevention (ERP), formation of hierarchy, conduction of the first step.

Homework review: The client continued to follow the activity schedule. She also tried to practice mindfulness by focusing on the task she was doing. Moreover, she also completed a mini-survey of 5 people at home by asking about their thoughts and relevant behaviors.

Techniques

Construction of hierarchy for ERP (Wells, 1997)

Rationale: To reduce the client’s compulsions and train her in dealing constructively with her anxiety by staying in the situation. Procedure: At first, she was briefed about the procedure and what was required by her. All steps were clarified and queries were answered. After the introduction, a hierarchy was developed by the client with the least anxiety provoking situation to the most. Each situation was also given a rating regarding the level of anxiety felt in those circumstances. Outcome: The client was able to construct the hierarchy with the collaboration of the therapist.

Conduction of first step of the ERP (Wells, 1997)

Rationale: To make the client experience distressing thoughts but unable to perform neutralizing actions. Procedure: After listing down the situation, the client was exposed to the least anxiety provoking stimuli and then stopped from performing the anxiety reducing behavior. During the time anxiety ratings were taken across 1-minute intervals. The client was asked to wash her hands and then close the tap after it. At first the client was hesitant and did not close the tap. But after insistence, she closed the tap after which she was asked not to wipe or wash her hands rather let them remain as they were. It was seen that the client’s anxiety reached its peak within 2-3 minutes and remained high for approximately 10 minutes. The anxiety then reduced automatically until it was completely gone. Initially it was difficult for the client to carry on with the technique as she thought she won’t be able to handle the anxiety. Outcome: With repetitive insistence and exposure during the session, the client productively dealt with all her hierarchical situations.

Homework given: The next step of the hierarchy was given as homework and the client was asked to make her daughter sit near her while she was doing it. The co-therapist was designated to refrain the client from performing any neutralizing behavior and also monitor her anxiety.

Session No.7                                          Time of session: 45 minutes

Session Agenda

Verbal Reattribution (Questioning the evidence and questioning the mechanism)

Homework review: The client asked about the second step of the hierarchy. She reported that she was able to deal with the second situation in 2-3 days. She repeatedly did it throughout the day and by continuous practice she did not felt the need to perform her previous behaviors. Moreover, she also told that she tried to restructure her thought during ERP as well which helped her continuing with the procedure

Techniques

Questioning the evidence (Verbal Reattribution) (Wells, 1997)

Rationale: To make the client identify evidence and counter evidence of thought in order to disconfirm her beliefs. Procedure: The most frequent and distressing thought of Na-paaki was addressed by this technique. She was first asked to define what Na-paaki was and how she got to know that the objects were Na-paak. As the client did not have problems with dirt she did not focus on it. Hence, she had no strong or visible evidence of proving that something was Napaak. She reported that she just felt like the objects were Napaak when someone touched it after coming from outside or visiting the washroom. Outcome: This led to the disconfirmation of her beliefs that when there is no solid evidence of a phenomenon, then how is it possible to have happened. The technique was helpful in thought-event diffusion of the client.

Questioning the mechanism (Wells, 1997)

Rationale: To question the client’s understanding of how things got unclean and what ‘Ahkamaat’ have been given regarding Na-paaki in the religion. Procedure: The disconfirmation of beliefs was furthered by discussing empirical quotes (Ayahs and Ahadees) about Napaaki. She herself told how an object or place would become Napaak based on the religious beliefs. The instances were limited (2-3) and she realized that there was a different between dirt and Napaaki. Her belief around the strictness of achieving purity in the religion decreased and she found that it give space and freedom for minor mistakes. Outcome: The whole process of questioning the thoughts affected the client greatly and major improvement was seen after the client was convinced.

Homework given: The client was asked to continue her activity schedule and add a visit to the neighbors’ house in it. She was also asked to question her own thoughts each time they came by finding evidences and convincing her upon the illogical cognitions.

Session No.8                                               Time of session: 45 minutes

Session Agenda

ERP continued, Relaxation exercise

Homework review: The client was inquired about her emotions and thought processes across the past week and how she helped herself in coping with the distressing thoughts. The client told that she evaluated evidence regarding each thought that came and tried to reduce the consequent compulsion she previously did by restricting herself and using the techniques learned during session.

Review of previous session: In order to make the concepts more clear and revise them for the client, verbal reattribution strategies were discussed again and all of the client’s ambiguities were answered.

Techniques

Continuation of hierarchy

Rationale: To make the client exposed towards more anxiety provoking situations and make her deal with them as well. Procedure: The third and fourth step of the hierarchy was carried out in the session. The third step was carried out by asking the client to touch his feet and shoes thoroughly and then refrain from washing hands. She was asked to talk to the therapist randomly and concentrate on handling the situation without carrying out any compulsion. The client was given ample time for her anxiety to reduce from 100% to 10-20%. She was then asked to carry out the third step of touching the floor and then stay in the same situation. The procedure for preventing from washing was followed. Each situation was repeated 2-3 times. Outcome: The client felt extremely distressful in the start. She disagreed on carrying out the task but the therapist tried to reassure the client. After being convinced, the client carried out the task and handled them fairly well.

Progressive muscle relaxation (Bernstein & Borkovec, 1973)

Rationale: To reduce the client’s muscle tension and bodily pain. Procedure: The client was first told the rationale of the technique and how it will help her in the treatment of bodily pains. After that she was told about the 16 muscles that would be focused upon in the exercise. The therapist then demonstrated how each muscle will be tensed and then relaxed. After the elaborate explanation, the client was asked to relax on her chair and then each muscle of the client was focused. She was asked to first tense each muscle then relaxing it. Double time was given for the client to relax each muscle as compared to the duration of tension. The neck, shoulder and thigh muscles were focused more as the client felt more pain in them. Outcome: She understood the procedure and felt relaxed after the exercise.

Homework given: The third and fourth step of the hierarchy was given to practice at home as well. She was also asked to practice PMR daily before sleeping. A handout was given to the client in which a diagram of each muscle was provided in case the client forgot.

Session No.9                                           Time of session: 45 minutes

Session Agenda

Doubt reduction techniques, Review and therapy blueprint, Post-assessment

Homework review: She was asked if she did the exercise she was told. The client complied with all the instructions. She did the relaxation exercise 5 days per week before sleeping. She dedicated 20 minutes to the exercise daily. Moreover she continued to do the tasks given in ERP and reported that she felt less anxious now.

Techniques

Doubt Reduction techniques (Wells, 1997)

Rationale: To that make client’s behavior ‘stand out’ in memory and will consequently reduce the doubt that motivates checking. Procedure: The client was asked to divide each contamination tasks into smaller steps and focus on those steps while they were being done. For example if she went to the restroom, steps such as opening the door, using the toilet, using the water, washing hands, closing tap and coming out of the washroom were defined. She was asked to revise each step while doing it and then consider the task completed. She was also asked to tick mark each activity after they were done by her. Outcome: This made her less doubtful for each task and she revisited each task relatively less.

Relapse Prevention and Therapy Blueprint (Wells, 1997)

Rationale: To revise all techniques and answer all queries of the client. Procedure: The client’s symptoms were first revised with which she initially sought treatment. After the review of problems, solutions that were implemented were focused. Each technique was revised and the rationale of each procedure was explained again. Most effective strategies were also identified. She was also briefed about the steps she would take if future problems occurred and how she should continue the short term goals. Outcome: The review helped in summarizing the therapeutic sessions and to identify most valid techniques.

Post Assessment

Rationale: To assess the difference between the severity of pre-treatment ratings and post treatment ratings of symptoms. Procedure: The client was asked to rate all her symptoms again on a scale of 0-10. Outcome:

Symptoms Pre-treatment Ratings (0-10) Post-treatment Ratings (0-10)
Thoughts of uncleanliness ‘Na-paaki’ regarding clothes, house floor, sofas etc. 10 4
Distress because of washing hands, clothes, household items, floor etc. 10 2
Inability to control or suppress thoughts 10 2
Dissatisfaction after using the washroom, washing hands or clothes 9 3
Anger, frustration, irritability 9 3
Unable to remember or recall immediate actions 9 1
Social withdrawal, remaining inside the house 8 3
Hopelessness and worry about the treatment of problems. 8 1
Inability to handle house chores effectively 7 3

Homework given: Therapy blueprint was given. A chart for the frequency and intensity of obsessions and compulsions was given again to determine post-treatment ratings.

Session No.10 (Follow-up session)               Time of session: 45 minutes

Session Agenda

Follow-up on the progress of goals.

Homework review: The chart for obsessions and compulsions was revied to determine post-treatment rating of frequency and intensity of obsessions.

Area of Baseline Pre-treatment Rating Post-treatment rating
Frequency of obsessions 25-30 times per day 5-6 times per day
Intensity of the drive to perform compulsion 9 on average 4 on average
Intensity of emotions 8 on average 4 on average
Duration of obsession Variable (Ranges from 1 minute to an hour) 1-10 minutes
Duration of compulsion  (5-10 minutes in washing body parts, 30-40 minutes in bathing and 2-3 hours in washing clothes) 1-2 times per day

Techniques

Follow-up

Rationale: To check the compliance of client with treatment techniques and to asses the betterment in all symptoms. Procedure: An interview was conducted with the client and her husband to assess the improvement in the symptoms. Outcome: Both the client and her husband informed that she was considerably better and she was trying hard to completely eliminate all her problems.

Therapeutic outcome

The therapy was effective in dealing and subsiding the client’s obsessions and compulsions. It improved the client’s quality of life and made her more cheerful, hopeful and functional. The client’s compliance and strategies increased the outcome of the therapy.

Limitations and Suggestions

The client was initially reluctant and non-compliant with the therapist’s suggestions but with repeated insistence she started to follow the therapeutic protocol.

The client was irregular in her sessions hence, long gaps occurred between some sessions. The client was requested to follow the schedule so she became regular after 4th session.

References;
  • American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Washington, DC: Author.
  • Moritz, S., Von Muehlenen, A., Randjbar, S., Fricke, S., & Jelinek, L. (2009). Evidence for an attentional bias for washing-and checking-relevant stimuli in obsessive–compulsive disorder. Journal of the International Neuropsychological Society, 15(03), 365-371.
  • Tata, P. R., Leibowitz, J. A., Prunty, M. J., Cameron, M., & Pickering, A. D. (1996). Attentional bias in obsessional compulsive disorder. Behaviour Research and Therapy, 34(1), 53-60.
  • Timpano, K. R., Keough, M. E., Mahaffey, B., Schmidt, N. B., & Abramowitz, J. (2010). Parenting and obsessive compulsive symptoms: Implications of authoritarian parenting. Journal of Cognitive Psychotherapy, 24(3), 151-164.
  • Wells, A. (1997). Cognitive Therapy of Anxiety Disorders: A practice manual and conceptual guide (1st ed.). New York: John Wiley & Sons.

Case 4

Case Summary

            The client was a 32 years old man who had achieved his education up to MBA, was serving as a police officer and belonged to middle socioeconomic family. He came to the Centre for Clinical Psychology with the complaints of shyness, confusion in social situations, inability to talk adequately in front of people on a higher pedestal, sweating, blushing of face, fear of embarrassment, anticipation of negative evaluation, avoidance of social interactions and disturbance in social life. He was informally assessed through a clinical and diagnostic interview, mental status examination, visual analogue, dysfunctional thought record while the Liebowitz Social Anxiety Scale was implemented as formal assessment. After thorough examination, the client was diagnosed with Social Anxiety Disorder. He was treated on the lines of Cognitive Behavior Therapy through the techniques of cognitive restricting, socialization, cost-benefit analysis, assertiveness training etc. The pre and post assessment of the client showed a significant decline in the client’s complaints and symptoms showing efficacy of the therapy.

Bio Data

Name: S.T.

Age: 32 years

Gender: Male

Education: MBA

Occupation: Police Officer

No. of Siblings: 3 (1 sister, 2 brothers)

Birth order: First born

Marital Status: Single

Religion: Islam

Informant: Client Himself

Reason and Source of Referral

The client came to the Centre for Clinical Psychology with the complaints of shyness, confusion in social situations, inability to talk adequately in front of people on a higher pedestal, sweating, blushing of face, fear of embarrassment, anticipation of negative evaluation, avoidance of social interactions and disturbance in social life. The client was referred to a trainee clinical psychologist for the assessment and management of his symptoms.

Presenting Complaints

Table1: Presenting Complaints of the Client

Duration Complaints
From 2-3 years
I am ashamed to go in crowd. If anyone is near me than i cant think properly
From 2-3 years I get confused very quickly. Can’t even talk. Can’t even give the correct answer
From 2-3 years Where I think there are people older than me, I can’t perform properly
From 2-3 years In any such situation I start sweating. The face turns red
From 2-3 years Where people are present, despite the preparation, it seems that I will do something wrong, or something will come wrong out of my mouth
From 2-3 years Every time i worry about what people will think
From 2-3 years I often refuse to go to places where people will be. I like to stay in the room on such occasions.

History of Present Illness

The client’s problems date back to his childhood when he was studying in school for primary education. He was in 5th grade when he had to go through a rough phase of life and did not have adequate support to go through the phase. During his time in 5th grade, he was bullied by his seniors multiple times. The client was a naturally shy person and the senior boys of the school took advantage of him. They usually came to him in the recess time and asked him to do favors such as serving them lunch, bringing them food from the canteen, making their practical copies or fetching books from the library. In addition they would confiscate his lunch, geometry and books and also tore down his copies. This happened almost daily which made the client skip school but he was unable to tell his parents about it. He had the perception that his parents will get angry upon him for making excuses and telling lies. His grades declined due to the stress and his relationships with the teachers also declined. His teachers perceived him as a below average student who was not interested in studies and was not confident. The client started to remain in his class during recess and when the teachers noticed his behavior they thought that it was due to his shyness. They held parent teacher meetings to discuss the client’s problems but all of them thought that the grades were low as the client was not interested in studies and school. The client did not share his problems with his siblings or parents neither did he make friends at school. The 5th grade passed in the same circumstances after which his parents decided to change his school so that the grades may improve.

The next school proved to be better for the client but he was still afraid of the elder boys. The school had better management and kept discipline during the school timing. This made the client focus on his studies more than the issue of people teasing him or bullying him. His grades improved and he made friends in the new place. His teachers started to hold a positive view about him. His performance in sports improved but he never took the initiative to speak in class by himself or taking part in extra-curricular activities. He remained a shy student but academically improved to a greater degree. His studies after that went on without any hurdles. He passed his matriculation and intermediate with above average grades. During his bachelors and masters as well he performed satisfactorily but still remained shy while talking to others especially girls.

After he achieved his postgraduate education, he decided to go into the Police force. He was motivated by his childhood experiences and wanted to stand against bullying. He wanted to overcome his shyness and perform better so applied in the forces and got accepted for the program. Throughout the training program and his 2 years of service he did not face any problem regarding his social behavior. In 2016, he faced another psychological stressor which triggered his current symptoms. He was given a task by his seniors to prepare a presentation which had to be given in front of his superiors and foreign officials. He tried to decline the offer but he was insisted on doing so. The presentation had to be given after a month of the proposal and that month was the most stressful for the client. He consulted each of his colleagues for help and guidance. He prepared the presentation investing all his energy to do a commendable job and practiced innumerably in front of his friends and colleagues. On the day of presentation, he felt extremely anxious and fearful. The client started to give the presentation but felt dizzy and within 5 minutes of presenting, he felt an increase in his heartbeat and excessive sweating. He had to reach for water repeatedly as he felt dizzy but completed the presentation adequately. There was applause round the hall and he was given positive feedback upon his performance. After the presentation, he reported to his immediate senior who gave feedback on his performance. He was told that he was appearing nervous, his voice was shaky, face was flushed red and he was sweating a lot. Along with these comments, positive compliments were also given. The following night, client could not sleep as he kept on pondering upon the comments of his boss.

After the incident, there were frequent episodes of anxiousness, sweating and inability to talk when the client had to talk in his friend’s circle or in professional meetings. He started to assume that his face and ears were getting red and he would feel embarrassed. Whenever the symptoms appeared, he left the situation or meeting. This compromised his performance chart because of which he considered to seek treatment for his issues. He consulted his friends for reassurance and opinion to get better. One of his friends recommended him to see a psychiatrist or a psychologist. He then came to the Centre for Clinical Psychology with his complaints for the management of his symptoms.

He did not report any physical or sexual abuse. He was taking any medications at the moment neither was there a history of accident, injury or organic disease.

Background History

Family History

            Father. The client’s father was a 65 years old, uneducated business man. He has his own fields in a village where he use to grow crops along with his brother. He was diagnosed with blood pressure for which he took medications. He was a clam natured person who got angry rarely. He rarely expressed his anger and also kept quiet mostly. He was a highly religious person. His relationships with his siblings, wife and children were satisfactory. The client’s relationship with his father was also respectful and caring but due to the client’s shyness he still felt some degree of fear from his father. They occasionally sat down to discuss business matters but the meetings gradually reduced when the client had to move away after his joining in the police force. They still talked over the phone and cared about each other. The client’s childhood experience of bullying was not shared by his father as he thought that his complaints would be misperceived. Other than that, the client was able to discuss most of his issues with his father.

Mother. The client’s mother was in her fifties, educated up to intermediate and was a housewife. The client described her as a shy, calm and down-to-earth person who was always ready to help others. She had no physical or psychological problems. She was also religious and tried to make her children turn towards religion as well. Her relationship with the client was loving and caring. She dedicated her life for the upbringing of her children and always remained concerned about their well-being. The client usually called her mother and shared his problems with her after he entered adulthood.

The client’s parents had a satisfactory relationship betweem them. They had been married for 34 years but the interaction decreased in the last 10 years. Both remained indulged in their work and were satisfied by each other.

First born was client himself.

            Second born brother. The client’s brother was 28 years old currently doing his masters from a reputable university. He was an outgoing, social and cheerful person. He was confident according to the report of the client. The client and his brother had a distant relationship as he always had to behave like the bigger brother. He did not feel interested in his brother’s activities and had to act like a grown up in the house as well. Both the brothers still cared and helped each other in the time of need.

Third born brother. The younger brother of the client was 22 years old and was doing his bachelors in Computer Science. He was an intelligent and above average student. The client’s brothers had mutual understanding and harmony between them but the client himself did not have close bonding with both the brothers. His younger brother also did not get frank with the client out of respect and obedience. The client was treated as a father figure. The client tried to keep his necessities fulfilled and would give him gifts whenever he visited home.

Last born sister. The client’s youngest sibling was his sister who was 20 years old and was studying in a nearby college. She was the most pampered child being the youngest and only sister. The client had immense love for her sister. Although their relationship was also not close as the client lived away but still they had respect and care between them. The client wished all the good for her sister.

General Home Atmosphere. The client belonged to a middle socio-economic family. His household environment was always calm and nourishing. There were seldom fights or screaming. The children were asked to live harmoniously. The authority figure of the house was the client’s father but discussed issues with his wife. The family was moderately social. They visited their relatives house frequently and also treated their guests well.

Personal History

Birth and Childhood History. The client was born after a complete gestation period of 9 months through a C-section. His vaccinations were properly done and developmental milestones were achieved at appropriate age. The client did not remember much of his early childhood neither had a discussion on this topic with his parents. He reported that he had a neurotic trait of rubbing his fingers whenever he was nervous. He used to rub his nails on his fingers pressing them deeply into the skin. The habit automatically vanished when he entered adolescence.

Educational History. The client started his education at the age of 6 years. He was put in a local school as his father believed that children can excel on their own as well. Until the fourth class the client remained an average and obedient student. In 5th class, he had to face bullying by the senior boys in school who used the client for various purposes. The client was never physically hit or sexually assaulted but the frequent threats of the seniors kept him scared. The client started to remain in his classrooms and in front of his teachers. His teachers became dissatisfied with his performance and informed his parents about low grades. None of the parents or teachers knew about the bullying neither were they told by the client. After the below average result in 5th grade, the client’s school was changed and he got rid of the bullies. From 6th grade onwards, client performance improved but he still remained a shy student he was good in sports but did not take active participation in any of the extra-curricular activities. He continued his education up to masters with satisfactory percentage. He did not have to face any other psychological stressor throughout his academic career, rather maintained healthy relationship with his teachers, colleagues and fellow students. He remained satisfied with his educational life and considered the bullying episode as a learning opportunity.

Pubertal and Sexual History. The client achieved puberty at the age of 4 years when started to notice changes in his genitals, face structure and voice. He did not face any emotional disturbances at that time. The client sometimes watched erotic movies after he hit his puberty but he did not have any history of homosexual or heterosexual experiences. He also did not report any incidence of sexual abuse or harassment.

Occupational History. The client joined the police force after his postgraduate education. Despite being a shy person, he was able to get in, in the job. He had admirable performance at his job in the initial two years. He maintained satisfactory relationship with his seniors. In the 3rd year of his service, the client had to face a stressful situation when he had to give a presentation in front of a hall of senior officers and foreign officials. The client felt extremely nervous and anxious before giving the presentation. Even after the performance, he was given both positive and negative comments but he kept on focusing on the negative ones and thus became more conscious of his actions. After the event, his performance declined slightly as he started to avoid big gatherings or situations in which he may become the focus of attention. On the other hand, the client’s relationship with his colleagues was satisfactory and he presented himself to all friends in the time of need. He also shared his symptoms and problems with two of his close friends who recommended him to seek psychological advice.

Pre-morbid Personality. The client had a shy personality since childhood but he used to remain calm and relaxed while meeting people. He would give answers with adequate speech quality. He was not reluctant in going to gatherings rather encouraged his friends to go out as well. Moreover, he did not use to worry excessively about his appearance or performance. He remained composed in front of his seniors and performed his job well. His frustration tolerance was high and remained steadfast in his work. He had more interactions with his friends, colleagues and relatives before the symptoms started to occur.

Psychological Assessment

Informal Assessment

Informal assessment was conducted on the following lines

  • Clinical Interview
  • Mental Status Examination
  • Visual Analogue
  • Dysfunctional Thought Record

  Clinical Interview

Informed consent was obtained from the client to ensure he was permitting therapy. A clinical interview was held with the client to assess the symptoms and its intensity, duration, settings and frequency. Moreover, the interview helped in eliciting history regarding the client’s presenting complaints, reasons for development, triggering factors and the factors through which the symptoms were being maintained. It also aided in finding the etiological factors and assessing the line of treatment for the client.

Mental Status Examination

The client was a tall heighted man having a muscular built and appearing to be in his thirties. He was wearing neat and tidy clothes and his hygiene was maintained. He sat on the chair with a straight posture and his actions were greatly pronounced. He kept on moving his leg. He maintained less eye contact while talking but kept his hands clenched tightly. His mood and affect were congruent. He appeared to have a pleasant mood at the time of the interview but he reported that he remained irritable mostly. He was attentive towards the therapist and maintained concentration throughout the sessions. His tone of speech was high and rate of speech was fast. His abstract thinking and judgment was also adequately present. He had a fair insight regarding his problems.

Visual Analogue

The client was asked to rate his problems on a scale of 0 to 10 in order to know her perspective on the degree of problems caused by the symptoms and her priority of dealing with symptoms. He was explained that 0 meant that the problem was least problematic while 10 meant the problem was most problematic. This helped in creating a symptom specific management plan based on the severity and priority of each symptom.

Table 2: Symptoms and their severity according to the client

Symptoms Severity (0-10)
Feeling of embarrassment while going in front of people 9
Fear of scrutiny, evaluated or being ashamed 9
Fear of performing inadequately 9
Becoming confused in front of others 9
Avoiding presentation or social activities 8
Sweating, flushing of face 8

Dysfunctional Thought Record

The client was given a dysfunctional thought record to take into account the cognitive component of his problems. It aided in later conceptualizing the symptoms to him.

Quantitative Analysis

Table 3: Areas of the DTR and the client’s responses

Frequency of Thoughts 1-2 times per day
Intensity of Emotions 9 on average
Intensity of Physiological responses 9 on average

Qualitative Analysis

Table 4: Areas of the DTR and the client’s responses

Settings/Situations Presence of seniors

Presence of friends or colleagues especially females

Talking to someone superior

Going in areas where there are a number of people

Content of thought I will not perform adequately

People will think I am dumb

People will judge me wrongly

I will do something stupid

People will notice my nervousness, sweating and flushing of face

Emotions Anxiousness, Irritability
Physiological responses Heavy sweating, increased heartbeat, confusion, flushing of  face
Behavioral/ Cognitive responses Avoiding parties or situation in which more people are present

Leaving settings in which seniors are present

Not taking initiatives

Avoiding females

Formal Assessment

            Formal assessment was carried out through:

  • Liebowitz Social Anxiety Scale

Liebowitz Social Anxiety Scale

The scale was administered on the client to obtain a detailed analysis of the situations in which he felt anxious and the degree of his anxiety. The scale also tailored to offer the client’s urge to avoid social situations (Liebowitz, 1987).  The scale had 24 questions and the client was asked to rate each question on a scale of 0 to 3 for the level of anxiety and degree to which he wanted to avoid those situations.

Quantitative Analysis

Table 5: Area and client’s scores on the Liebowitz Social Anxiety Scale

Area Client’s scores
Performance Anxiety subscale 53
Social situation subscale 15
Total Score 68 (above cutoff)

Qualitative Analysis

The client’s score correspond to the very probable level of Social Anxiety Disorder. It is above the cut off i.e. 30 which means that the client had a high probability of having Social Anxiety Disorder. It is clear through the results that the client had an excessive fear of performance anxiety while situations such as calling people, expressing disagreement or interaction with unknown people were not problematic for the client. He expressed the most anxiety in situations where he was the center of attention and the gathering was composed og known people. There was high probability of the client to avoid these situations as well.

Summary of Informal and Formal Assessment

The detailed assessment of the client shows that he considers himself unable to interact or perform in social situations and hence tends to avoid them. He experiences distress, anxiety and irritability in these conditions because of which his social and occupational functioning was being compromised.

Diagnosis

(F40.10) 300.23 Social Anxiety Disorder

Differential Diagnoses

Panic Disorder: Panic disorder is diagnosed in an individual when there are recurrent episodes of physiological arousal and his major focus is on the recurrence of the attack. On the contrary, social anxiety disorder is diagnosed when the client has the primary concern of negative evaluation. Moreover, panic attack can be experienced by an individual while he is alone as well but social anxiety disorder is specific to social situation even if it’s the presence of a single person (APA, 2013).

Normative Shyness: Normative shyness is also a trait that is found in many individuals but when it exceeds a certain limit and starts to cause disturbance in social, occupational functioning then it is diagnosed a social anxiety disorder. Moreover the fear of negative evaluation greatly signifies the diagnosis. Due to the presence of concerns regarding scrutiny and evaluation and the disturbance in social and occupational functioning, the client was diagnosed with social anxiety disorder (APA, 2013).

Prognosis

The client had good prognosis as he has fair insight about his issues and was also willing to take the therapy. Moreover, his symptom severity also indicated that they can be controlled and maintained fairly well. His compliance and dedication also increased the prognostic value of therapeutic techniques.

Case Formulation

The present client was a 32 years male presenting with anxiety in social situations, confusion when replying inability to talk in front of people and physiological responses. He was diagnosed with Social Anxiety Disorder according to the Diagnostic Statistical Manual. The developmental psychopathology of social anxiety disorder points out that childhood shyness can lead to future acquisition of Social Anxiety Disorder (SAD). Ollendick and Hirshfeld-Becker (2002) studied the developmental causes of SAD and found that children who are shy are not gven proper guidance to tackle with their shyness later develop extreme anxiety in dealing with people or interacting in social situation. They develop a consistent pattern of anxiousness in their repertoire which can contribute to the enhanced risk of developing SAD. The client’s case can be related to this as he was shy from his childhood. He was reluctant in taking initiatives in school as well so the same pattern was being followed now. Hence, his disorder can be attributed to his prior functioning as a child.

McCabe and his colleagues (2010) studied the relationship of bullying in childhood and the increased probability of developing an anxiety disorder. They found that 92% of the individuals who self-reported bullying indeed developed Social Phobia. They attributed that aversive conditioning experiences, such as severe teasing, have been proposed to play a role in the development of social phobia and that the core feature of social phobia is a fear of social situations in which a person may be embarrassed or humiliated. This conditioning thus associates bullying with the acquisition of SAD. The present client also faced bullying in his school years which was kept hidden from authority figures and not handled appropriately. The assumptions and beliefs formed at that time may have now triggered the disorder in the client presently.

Behaviorists believe that social phobia is a result of a two factor conditioning model. That is, a person could have a negative social experience (directly, through modeling, or through verbal instruction) and become classically conditioned to fear similar situations, which the person then avoids. Through operant conditioning, this avoidance behavior is maintained because it reduces the fear the person experiences. There are few opportunities for the conditioned fear to be extinguished because the person tends to avoid social situations. Even when the person interacts with others, he or she may show avoidant behavior in smaller ways that have been labeled as safety behaviors. The client’s dysfunctions were also being held strongly by the two types of conditioning. His incident of performing in front of a room full of senior authority figures, his nervousness and the biased focusing on negative comments given by his boss, made the situations fearful for him so he developed performance anxiety. He started to link further performances with that one incident and believed that the same would occur in all situations and he will be negatively evaluated by all. Because of this, the client was unable to perform in future situations as well.

Cognitive theorists explain SAD in the terms of dysfunctional cognitions and maladaptive thinking patterns. They propose that people with this disorder hold a group of social beliefs and expectations that consistently work against them. Among the beliefs are, ‘I won’t be able to perform adequately’, ‘I must give a 100%’, ‘There is no chance of any mistake’, ‘People may think less off me’. Cognitive theorists hold that, because of these beliefs, people with social anxiety disorder keep anticipating that social disasters will occur, and they repeatedly perform “avoidance” and “safety” behaviors to help prevent or reduce such disasters. The client also presented with the same beliefs. He held unrealistically high social standards and expected himself to perform perfectly in social situations, even though he had never been so vocal or good with expressing himself. Moreover, his negative anticipation and low confidence in himself triggered a self-fulfilling prophecy making it difficult for him to perform in social situations.

Case Conceptualization (Clark & Wells, 1995)

Management Plan

The management plan was devised specific to each symptom on the lines of Cognitive Behavior Therapy.

Short-Term Goals
Short Term Goals Therapeutic Intervention
To develop therapeutic alliance with the client Collaborative empiricism, empathy, active listening, unconditional positive regard
To educate client about his illness, symptoms, development and maintaining factors Psycho-education

Normalization

Socialization with the CBT model

Productive and unproductive worry

Challenging faulty beliefs and generating alternatives Cognitive restructuring (Triple column)

Cost-benefit analysis of thoughts

Practicing social situations and decreasing avoidance/ safety behaviors Systematic Desensitization

Coping Statements

Eliminating physiological symptoms Progressive Muscle Relaxation
To improve communication and confidence Assertiveness Training (Role-Playing)
Relapse Prevention Therapy Blueprint
Long-Term Goals
  • Continuation of short term goals
  • Follow-up sessions
  • Social Skills Training

Session Reports/Management Plan

Session No.1                                          Time of session: 45 minutes

Session Agenda

Develop therapeutic alliance, History taking, Mental Status Examination, Symptom elicitation and subjective ratings

Techniques

History taking

Rationale: To obtain a comprehensive account of the development of client’s problems, its predisposing, maintaining and precipitating factors. Procedure: Information about the client’s symptoms, their intensity and presenting situations were elicited. Moreover, client’s support system, social functioning, familial life and personal views were also obtained in the history Outcome: The client elaborately discussed all his life domains and cooperated with the client in giving every piece of information.

Mental Status Examination

Rationale: To assess the client’s current level of functioning (cognitive, behavioral, affective and general appearance). Procedure: The therapist observed several of the areas herself such as grooming, eye contact, posture, gait, speech etc. While some questions were directly asked from the client i.e. questions about cognitive functioning, mood, insight etc. Outcome: The significant information obtained through MSE was the anxious and irritable mood of the client, less eye contact while talking, shaky voice and fidgeting while talking.

Symptoms Elicitation and Subjective Rating

Rationale: To understand the client’s problems, elicit disorder specific symptoms and obtain a subjective rating of each symptom. Procedure: The client was asked to tell about the symptoms she experienced while the therapist tracked down the relevant and specific details. Moreover, the client rated her symptoms on a scale of 0-10. Outcome: The procedure helped in identifying the specific severity of each symptom and helped in prioritizing them for treatment.

Therapeutic Alliance

Rationale: To maximize the feeling of comfort and straightforwardness between the therapist and the client. Procedure: It was established through emotional reciprocity which included the therapist’s active listening and responding with appropriate non-verbal communication. The therapist also paraphrased repeatedly during the session to ensure clarity of client’s description and make him certain that he was being understood. The client was also given empathy and unconditional positive regard which was practiced by having a non-judgmental attitude during the session and understanding the client’s problems from his point of view. Any verbal or non-verbal of downsizing the issues or considering them less important were avoided. Outcome: The strong therapeutic alliance developed in the initial sessions led to effectiveness of therapy. Rapport was effectively developed with the client it kept the client motivated for treatment throughout the therapeutic process for procedures like homework assignments and other behavioral strategies.

Session No.2                                   Time of session: 45 minutes

Session Agenda

History taking (continued), Differential diagnoses, formal assessment (Liebowitz Social Anxiety Scale)

Review of previous session: The history obtained in the first session was reviewed to continue in the current session.

Techniques

History taking (continued)

Rationale: To probe more information about the client’s past life and obtain data which was previously unable to get. Procedure: The client was asked about his symptoms in more detail and about the situations in which he previously felt the same way. His incident of the performing in the presentation was discussed in depth. Outcome: The review of history helped in obtaining more information that would aid in treatment.

Differential Diagnoses (American Psychological Association, 2013)

Rationale: To obtain a distinct analysis of the diagnoses and rule out implausible ones. Procedure: The diagnosis for Social Anxiety Disorder was probed more while symptoms of Generalized Anxiety Disorder, Social Phobia and Normal shyness were ruled out. Outcome: It helped in confirming the client’s diagnosis of Social Anxiety Disorder.

Formal assessment (Liebowitz Social Anxiety Scale, 1987)

Rationale: To obtain more information about the client’s problems by using standardized and developed tools. Procedure: The client was given a questionnaire during the session. He was explicitly given the instructions needed to complete the test. Items and their options were explained. He was given ample time to complete the questionnaire with ease. Outcome:  He scored high in experiencing anxiety in social situations and experienced significant performance anxiety in those settings.

Homework given: Dysfunctional thought record was given for the client to fill.

Session No.3                                      Time of session: 45 minutes

Session Agenda

Psycho-education and normalization, socialization, productive and non-productive worry.

Homework review: The DTR filled by the client was reviewed which helped in identifying the situations in which the client felt anxious, thoughts that occupied his mind and his reactions towards those situations.

Techniques

Psycho-education and Normalization (Wells, 1997)

Rationale: To educate the client regarding his diagnosis, their causes, development, treatment options etc. Procedure: The client was educated regarding his illness, the triggering and maintaining factor and the fact that his symptoms were experienced by many other individuals. It helped the client in reviewing himself as part of a bigger community rather than being alone in the specific set of symptoms. While discussing about the prognosis of the client, he was told about collaborative empiricism and how therapy was to be conducted. He was educated about his active role in setting the agenda of therapy, setting short-term and long-term goals, his compliance with homework assignments and active communication with the therapist. Outcome: Normalizing the disorder proved comforting and effective for the client. The technique also proved to be beneficial for him to solve his queries.

Socialization (Wells, 1997)

Rationale: To make the client aware of the development and process of his symptoms. Procedure: The triggering factors in the model such as the particular social situation, assumptions that are activated and consequent behaviors were exemplified with the client to make the symptoms and their formation more explicit. Outcome: The client agreed with the CBT model and understood where intervention was to take place. He helped in identifying more examples from his life as well.

Productive and non-productive worry

Rationale: To make the client know the difference between the benefits and disadvantages of worry. Procedure: A productive worry is a concern about something that is plausible whereas unproductive worry is about useless things or things that have a little chance of happening (Leahy, 2003). He was explained how anticipating worry about events that have a low probability of happening and for which one has the least evidence can make the individual trapped into an unproductive cycle. The cycle does not lead to a solution rather just utilizes the person’s energy making him more tensed, helpless and lethargic. Outcome: He understood the difference between worrying and how he was stressing himself by unproductive worry.

Homework: Psycho-educational material was given to the client to review at home as well.

Session No.4                                     Time of session: 45 minutes

Session Agenda

Cognitive restructuring (Double-column), Cost-benefit analysis of thoughts

Review of previous session: Psycho-education and productive and non-productive was briefly reviewed to freshen the client’s understanding.

Techniques

Cognitive restructuring (Double-column) (Wells, 1997)

Rationale: To make the client identify his cognitive errors Procedure: The client’s dysfunctional thought record was kept in consideration after which thoughts were emphasized. He was briefed about the different cognitive distortions which an individual makes while thinking. Each mistake in thinking was explained with various examples after which the client was asked to identify his own distortions. A double column was made in which the client wrote down his irrational thoughts and identified the distortion by writing it down in front of the thought. Outcome: The client was able to identify mistakes in his thinking which made him realize the role cognitions played in exacerbating his symptoms.

Cost-benefit analysis of thoughts (Wells, 1997)

Rationale: To make the client understand the damage done by maladapative thoughts and confidence gained by positive and adaptive thoughts. Procedure: He was asked to list down the advantages and disadvantages of a maladaptive thought. After the identification, he was given an opposite positive thought and list down the benefits and disadvantages of that particular thought. The client wrote down all the pros and cons which came to his mind. Outcome: The disadvantages of maladaptive thought were more while the benefits of adaptive thought was significant hence indicating to the client that thought was proving to be destructive rather than the situation itself.

Homework given: The bibliotherapy of cognitive distortions was given to the client to take it along with him and identify more distortions in his thinking until the next session.

Session No.5                                              Time of session: 45 minutes

Session Agenda

Cognitive Restructuring (Triple column), Systematic desensitization, Relaxation exercise.

Review of previous session: The client was asked about the confusions he may have regarding the last session. Cognitive distortions were briefly explained again so that restricting may be continued in the present session as well.

Homework review: He was asked if he was able to identify his maladaptive thoughts and mistakes in thinking. He reported that he sometimes became conscious of his negative automatic thoughts and also tried to identify the errors in his thinking.

Techniques

Cognitive Restructuring (Triple column) (Wells, 1997)

Rationale: To make the client change his maladaptive thoughts into adaptive ones by eliminating cognitive errors. Procedure: The client’s already filled double column was now increased by putting a third column. He was explained about the double standards he was keeping for himself and how his perfectionism was causing him to perform poorly. He was then probed to write down more realistic, rational and adaptive thoughts in the third column which would ultimately help in subsiding his symptoms and realistically help in improving his performance. Outcome: He was able to do the required task easily but had to be constantly recommended to bring the adaptive thoughts into his repertoire rather than just writing them down.

Systematic desensitization (Introduction)

Rationale: To reduce the client’s avoidance behaviors by exposing him to anxiety provoking situations and coping with them. Procedure: The client was briefed about the process of this technique. He was told about the tasks he would be required to do and how he will cope with the situation. Outcome: The client was hesitant in continuing with the procedure but he was convinced with repetitive explanations about how he will benefit from the technique at the end.

Homework given: To continue triple column at home as well and practice to bring rational thoughts in the repertoire. 

Session No.6                                  Time of session: 45 minutes

Session Agenda

Relaxation exercises, formation of hierarchy and conduction of first step of Systematic Desensitization.

Review of previous session: The last session was reviewed to freshen the client’s understanding of the process of systematic desensitization so that it could be continued in the current session as well.

Techniques

Relaxation Exercises

Rationale: To teach the client how to cope with the stressful situations. Procedure: The client was taught progressive muscle relaxation to know the difference between the tensed and relaxed muscles. 16 muscles of the body were focused and altered in making them tensed and relaxed. Outcome: The client understood the exercise well and it helped in relaxing the client’s tensed muscles during stressful times.

Formation of hierarchy and Conduction of first step of the hierarchy (Miltenberger, 1997)

Rationale: To expose the client towards an anxiety provoking situation and try to cope with it. Procedure: The client was first helped in forming a hierarchy in which situations were listed down. The situations were specific in which the client felt anxious. A list was made which incorporated all situations and systematic units of distress were written down against each situation. The list was made in an ascending order depending on the SUDs. The first step in the ladder was to make the client talk to an unknown girl for 10-15 minutes. He was asked to sit in a room where a girl unknown to the client was brought inside. He was briefed before the meeting that he will have to talk to the girl about himself. The therapist constantly monitored the session. The client became confused during the time the girl sat there but eventually discussed his likes and dislikes and general information with her. He had to be prompted 2-3 times. After the meeting, the client was given feedback by the girl he talked to and by the therapist. He was told about his performance and the presence of any symptoms that he had assumed for himself. Outcome: The client was convinced that no one noticed his face flushing or sweating rather were more interested in his answers. He himself made assumptions and got worried upon them. The procedure was repeated again with another girl the therapist knew but the client didn’t.

Homework given: The client was asked to practice relaxation exercises twice a day and also expose himself to a situation where he had to talk to a female colleague. He was told to practice the techniques of cognitive restructuring and deep breathing to cope with the situation.

Session No.7                                  Time of session: 1 hour

Session Agenda

Continuation of Systematic desensitization and introduction to mindfulness

Review of previous session: The client was asked about his views regarding the last session and how it helped him. The client gave his own feedback about the things he should have done or said in the two meetings with unknown girls and how he could have improved his performance.

Homework review: The client practiced the relaxation exercises which soothed down his body. Moreover he also attempted to talk to his female colleague. He was able to do it for 5 minutes even though he was anxious. He controlled himself by revising the rational thoughts in his mind.

Techniques

Continuation of Systematic desensitization

Rationale: To expose the client to more anxiety-provoking situations and habituate the client ot relax himself. Procedure: 3 more steps of the hierarchy were carried out in this session. Talking on the phone in front of strangers, eating in public and talking to 3 unknown people were the tasks carried out by the client. The client was given ample time to stay in the situation and then relax himself by giving positive self-instructions and changing his cognitions. Moreover he also relaxed himself by using deep breathing. Outcome: The client was able to perform all the tasks but with hesitation because of which the tasks were again given as homework to practice at home.

Homework given: The client was asked to practice the hierarchy steps again at home along with the next two steps of the ladder. He was also asked to try to remain in the present in stressful situations according to the principles of mindfulness.

Session No.8                                         Time of session: 1 hour 15 minutes

Session Agenda

Systematic desensitization continued, therapy blueprint, post-assessment.

Homework review: He was asked about the hierarchy steps which were to be carried out at home. The client was successful in handling the situations without avoiding them. He had to go through them repeatedly to improve his performance.

Techniques

Continuation of systematic desensitization

Rationale: To expose the client to the most anxiety producing situation for him. Procedure: The client was asked to come prepared for a 10-slide presentation on his work which he will give to a group of people. The client gave the presentation to 4 unknown people after which feedback was given to him. His assumptions regarding his anxiety symptoms and his performance were discussed in the feedback. Outcome: The client was able to give the performance but with extreme sweating and anxiousness. For this purpose he was recommended to practice and go through this task again and again to get habituated and practice rational thoughts.

Therapy Blueprint

Rationale: To revise all the techniques done in previous sessions and provide a toolbox for the client to use to tackle with his symptoms in the future. Procedure: As the client had to leave early all techniques especially cognitive restricting and systematic desensitization were discussed. Moreover emphasis on positive self-instructions and practice of each technique was emphasized. Outcome: He understood the importance of each technique and decided when to employ which strategy. His confusions regarding the process were clarified.

Post-assessment

Rationale: To assess the difference in symptoms of the client from pre assessment. Procedure: The client was asked to rate his symptoms again on a scale of 0-10. He was also asked to attempt the Liebowitz Social Anxiety Scale again. Outcome: There was a significant difference between the pre and post assessment ratings of the client.

Visual Analogue

Table 7: Symptoms and their severity according to the client 

Symptoms Pre-treatment Severity (0-10) Post-treatment Severity (0-10)
Feeling of embarrassment while going in front of people 9 5
Fear of scrutiny, evaluated or being ashamed 9 4
Fear of performing inadequately 9 2
Becoming confused in front of others 9 4
Not being able to give correct answers or respond appropriately in front of seniors 8 3
Avoiding presentation or social activities 8 1
Sweating, flushing of face 8 3

Liebowitz Social Anxiety Scale

Table 8: Area and client’s scores on the Liebowitz Social Anxiety Scale

Area Pre-treatment scores Post-treatment scores
Performance Anxiety subscale 53 15
Social situation subscale 15 5
Total Score 68 20

Outcome of therapy

            The pre and post assessment of the client shows that the therapy was efficacious and there was betterment in the client’s symptoms. The client was now able to function better in his life and experience les anxiety in social situations.

Limitations and suggestions

Therapy had to be terminated after 8 sessions as the client had to complete a course in another city. He could not take the sessions further hence he was advised to seek treatment at his new place or come for a follow-up session after his course was over.

Also study: Counseling Case Report Sample

References;
  • American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Washington, DC: Author
  • Liebowitz, M. R. (1987). Social Phobia. Mod Probl Pharmacopsychiatry 22:141-173
  • McCabe, R. E., Antony, M. M., Summerfeldt, L. J., Liss, A., & Swinson, R. P. (2003). Preliminary examination of the relationship between anxiety disorders in adults and self-reported history of teasing or bullying experiences. Cognitive Behaviour Therapy, 32(4), 187-193.
  • Miltenberger, R. G. (1997). Behavior modification: Principles and procedures. United States of America: Brooks/Cole Publishing Company
  • Ollendick, T. H., & Hirshfeld-Becker, D. R. (2002). The developmental psychopathology of social anxiety disorder. Biological Psychiatry, 51(1), 44-58.
  • Wells, A. & Clark, D.M. (1997). Social phobia: A cognitive approach. Chichester: Wiley.

Related Posts

Leave a Comment