Jim is a 37 time old man who's suffering from various issues, such as panic, major depression and poor sleep. He is also living only in his apartment but has two daughters who live away from home. He has been working in a manufacturing plant but is off permanent because of his stress and anxiety and unhappiness. His current problems include thoughts of harming himself and having to worry. When he's in public he in addition has reported that he needs to return home where he seems safe that could be anticipated to sense hot and sweaty, therefore he discovers it difficult entering public places, which could be making a sociable life problematic for Jim. This may be causing Jim's depressive disorder as he is becoming increasingly lonesome and may be ruminating. Jim's thoughts, feelings and behaviours are contributing to a vicious circuit. By handling Jim's difficulties with anxiety and anxieties, Jim might be able to feel safe whilst going into open public places which, in the future, could allow him to attend work, therefore minimizing his major depression as he has less opportunity to ruminate. Therefore this circumstance formulation will concentrate on Jim's fear of giving his home (agoraphobia) and what others think of him whilst he's in public areas (interpersonal phobia). By responding to these issues, his thoughts of harming himself, major depression and his sleep problems will be indirectly resolved.
The conditional approach to stress and anxiety and agoraphobia recommended that fear was regarded as the central component which gives surge to avoidance behaviour. Research discovered that 81% of participants attributed starting point of agoraphobia to a fitness experience (Ost & Hugdahl, 1983). Further research discovered that the thought process in agoraphobia was associated with what you can do to them in public however, not always after having a fearful event (Klein, 1987). Therefore the formulation for the therapy has been based on the cognitive behaviour way (CB) first developed by Beck (1976). The CB strategy suggests that feelings, thoughts and behaviours are connected and can create a continuing cycle which one will get difficult to escape. This technique is multidimensional and can create a loop where behaviours may have an effect on emotions, cognitive behavioural therapy (CBT) is aimed at interrupting the cycle. Which means model which will be used for this case formulation is the Clark and Wells (1995) style of social anxiousness. This model is dependant on Clark's (1986) original model but includes techniques which will contribute to the persistent pattern. These processes are self-focussed attention and types of avoidance and safety behaviours. These procedures demonstrate what sort of circuit can continue if the safe practices strategies and thoughts aren't challenged. The formulation is based on the model of social panic which demonstrates the circuit of stress and fear which Jim is sense. It really is hypothesised that Jim is experiencing agoraphobia because he concerns public places and it is often associated with other mental problems, with Jim they are social anxiety and depressive disorder.
Based on the theory that Jim has agoraphobia with cultural anxiousness, this formulation will illustrate the circuit of his disorder using Clark and Wells (1995) model for interpersonal phobia (Shape 1. )
Step 1 - A communal situation triggers an assumption within Jim. For Jim the social situation is a general population place, then may fear that something could happen to him which could be found out by requesting "are you frightened of something taking place and if just what exactly?" This fear could cause him to feel a sense of social danger.
Step 2 - This assumption could lead him into perceiving a feeling of danger by means of interpersonal judgement, because he concerns about what other people think of him as he believes that they are looking at him and think he's weird. Most of Jim's attention will become internal as he starts to notice his own feelings and thoughts, resulting in self-focussed attention.
Step 3 - A identified sense of threat can then lead to sensory and cognitive symptoms; trembling, sensing hot and sweating. Jim feels that other folks can see the perspiration and stated that "it's pouring down my face" even though the therapist could not see the perspiration that Jim was recommending. Jim may be concentrating his attention on himself, noticing his symptoms which he perceives are producing a bigger impact. These somatic and cognitive symptoms develop a cycle with just how he processes himself as a public subject. Jim could hesitate of what you can do to him in a public place which contributes to his perception that he's being stared at and is also under pressure from other folks. This then causes him to experience symptoms such as trembling and feeling hot, finally this stage links back again to perceiving himself as looking weird to others which influences the perceived communal danger.
Step 4 - Another routine included in this particular model is the fact with protection behaviours of going back home which comes from the perceived interpersonal danger. This protection procedure then web links into somatic and sensory symptoms, which for Jim is the reduction of feeling hot and sweaty. He might have other protection behaviours which could be found by requesting "any kind of other methods you utilize to diminish your anxiety". This process, links back to the processing of self as a cultural object.
Step 5 - A final cycle which could be adding to Jim's social stress is that the safety behavior of staying at home may allow him to think he is only safe when he is at home. This links back to the communal assumption that if he is in public areas that something you can do to him, which links into the interpersonal danger of being judged and being under great pressure. This situation can then link back again to the public situation.
Social Situation
Public PlaceTherefore Jim's agoraphobia with social panic is a continuous circle with many loops which inter-relate.
4.
Activates Assumption
Fear that something will happen
Perceived Community Danger
Being stared at and regarded as weird
Processing of Personal as a Public Object
Image of self as sweating and looking odd.
Somatic and Cognitive Symptoms
Shaking, Hot, Sweating
Safety Behaviours
Going Home, Biting Toenails.
Figure 1. A Cognitive Behavioural Remedy Model of Jim's Agoraphobia with Public Anxiety predicated on Clark and Wells (1995) Model for Community Phobia.
5.
To test if the proposed hypothesis is right and therefore provide productive treatment for Jim then more info will be needed. One method of screening that Jim has sociable anxiety is to apply the Liebowitz Friendly Anxiety Scale (LSAS) (Liebowitz, 1987). This solution assesses social stress and anxiety within different situations, by having a self reporting method which Jim may feel convenient producing somewhat than talking to the therapist during early stages of remedy and is as possible as the clinician administered method (Fresco, Coles, Heimberg, Liebowitz, Hami, Stein & Goetz, 2001). It has been shown that the LSAS is a cost effective method to identify patients with public panic (Rytwinski, Fresco, Heimberg & Coles, 2008).
Assessment is necessary of doubts because agoraphobic patients are thought to be afraid of what you can do to them in public areas settings. The Agoraphobic Cognitions Questionnaire (ACQ) is a home reporting method which examines three dimensions; fear of physical in-capitation, fear of shedding control and fear of performing embarrassing (Hoffart, Friis & Martinsen, 1992). It has been found that those people who have agoraphobia with social phobia rate highest on worries of behaving embarrassing, therefore it is expected that Jim should rate highest on this scale. Another concern is to discover where in fact the agoraphobia stems from; therefore questions about his former will be relevant, to find the way the initial fear is rolling out. It's quite common for individuals with agoraphobia to are suffering from their problem when a close family member has deceased and are in bereavement during the starting point (Rachmen, 2004). Jim's partner may have deceased and for that reason may have developed his agoraphobia during bereavement as he might now have a fear of death or disease.
Some people develop agoraphobia following a fearful event therefore prior life experiences might well have produced his onset, and may be measured utilizing the Life Experience Survery (LES) (Sarason, Johnson & Siegal, 1978). The LES has been made to examine life experiences and coping methods. This would be great for Jim to see if there was a specific cause which he didn't package with effectively.
It is possible that because Jim feels he is unable to be in public, he does not feel a feeling of control over his life; this may explain the depression, as a low sense of control is associated with major depression (Cash, 1984). Overall it is thought that Jim's protection behaviour of staying in triggers him to ruminate, which could be contributing to his despair.
A final issue for examination with Jim would be to look at his mental imagery. Jim appears to be concerned with how others perceive him and feels they can easily see his symptoms. These mental images are an integral role in retaining his social stress and anxiety (Hirsch & Holmes, 2007). A method to examine Jim's imagery would be through the Sociable Phobia and Nervousness Inventory (SPAI). This solution assesses specific somatic symptoms, cognitions and behaviours across an array of fearful situations (Turner, Beidel & Dancu, 1989). The SPAI can determine whether Jim has social phobia only, agoraphobia by itself, or a combination.
All of the measures would be ideal for Jim so that his techniques and beliefs can be clarified. That is important to accomplish for client-therapist relationships. If Jim does not have the therapist knows him, then he might not exactly want to continue with therapy.
6.
Firstly Jim should understand the formulation which has been developed and understand how this will help him to get over his panic and phobia to be in public areas. Therefore Jim can guide the therapy and where he would like to focus his main concerns, that could be his sleep problems and thoughts of harming himself.
The treatments which may be most ideal for Jim are to struggle his negative thoughts. Jim will need types of how thoughts relate to bodily sensations, and how thoughts themselves can cause the physical sensations. Therefore by executing a test such as reading out indicator words and Jim analyzing the effects of the words, he will see how thoughts can cause physical reactions.
Another method that could be useful to Jim is that of role play (Anthony & Swinson, 2000). He could pretend he is in a general public setting up with the therapist whilst he is being filmed. Following the role play he could watch the video which would show that the sweating is not as visible as he feels. This would allow Jim's inner perceptions of himself to be challenged also to reattribute his thoughts. If this is successful Jim's anxiety in public areas could reduce as he might understand there are no reasons for people to "stare at him and think he's weird".
A method that could follow is graded publicity (desensitisation therapy). That is attained by having Jim take part in activities which exposes him slowly to anxiousness provoking situations with the actions and pace place by Jim. Therefore he may go to his front door, the following week he'll go to his garden/highway, this might increase his stress and anxiety so he'll need to execute this on several events till he realises that there surely is nothing to fear. Each activity is established to expose him to anxiety which is increased from the last activity, and only once this anxiety reduces will he need to check out another goal (Edelman, 2002).
One concern where therapy could be less successful is if it occurred in the office. This might cause problems for Jim as he seems anxious when in public. Therefore, remedy would become more successful if it occurred at Jim's home during the beginning of therapy. This would cause him less anxiety and even more willing to participate in therapy and invite for exposure to the public to happen slowly. Planning on quicker results than Jim is able to cope with may cause an unhealthy client-therapist relationship, which could bring about Jim's reluctance to attend therapy. It's important to develop a good client-therapist marriage because people that have social phobia often find it difficult to speak about personal issues (Veale, 2003).
Overall the treatment should reduce his agoraphobia and interpersonal anxiety, making him feel safe beyond his own house and allow a healthy life that will reduce the amount he doubts and improve Jim's ability to sleeping. Therefore, Jim will be able go back to work, supplying him less time to ruminate, leading to limiting his depressive disorder and thoughts of harming himself.
