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Case Formulation Essay Case chosen: Kristen I.

Case History

Kristen is a 38-year-old female and a mother of two. She was recently divorced. She has been working in the same company for over 6 years, securing a well-paid career in the upper level management. Kristen complained that she has been troubled by worrying thoughts constantly over the past 8 months, always thinking about the possibilities of losing her job and not being able to support her family. She is always feeling restless, anxious and exhausted. Her uncontrollable worries seriously impaired her attention and efficiency at work. She suffered from poor sleep. Kristen’s father has been facing a lot of difficulties in job seeking ever since he got laid off when she was still a child. Her mother is an ordinary housewife who adopts a rather intrusive parenting style towards Kristen. According to DSM-5, Kristen is diagnosed to have generalised anxiety disorder (American Psychiatric Association, 2013). It is evident that Kristen has excessive anxiety and worry for over 6 months about her work. She is unable to control the worry. Her anxiety and worry are associated with restlessness, difficulty concentrating or mind going blank, sleep disturbance and being easily fatigued. Her symptoms caused huge impairment in her social and occupational functioning. There is no evidence showing that she is a drug abuser or suffers from a medical condition, and her disturbance is not better explained by another mental disorder.

II.

Case Formulation

Precipitants It is hypothesised that the major precipitant of her generalised anxiety disorder is her recent divorce. Divorce often results in huge emotional distress and pain. Sharma (2011) examined the psychological impact of divorce women of varied age groups. She found that both younger women (aged 20-30) and older women (aged 30-40) experienced similarly high levels of anxiety following their divorce, showing that anxiety is a common problem faced by divorced women. Booth and Amato (1991) discovered that this kind of psychological distress is likely to persist for quite a while immediately after divorce. As a recently divorced mother, it is believed that Kristen’s onset of generalised anxiety disorder was triggered by the divorce. Divorce is usually considered as a failure in life. A person who divorced with his/her loved one may drown himself/herself in self-blame and self-doubt, thinking that he/she was just not adequate enough to keep the family intact and it is his/her fault that this unfortunate event occurred. As stated by Sharma (2011), divorce could cause fright and a huge blow to a women’s self-esteem. As a result, Kristen may worry a lot about committing even a tiny mistake at work and imagine how her inadequacy would lead to more and more failures in the future. This worrying thought backfired and adversely affected Kristen’s job performance, which in turn leads to greater anxiety. Also, the broken relationship has many implications for Kristen, such as the possibility of having to support the children all by herself in the coming years. Kristen may think that she cannot afford losing her two boys and her job because her husband, probably a huge pillar in her life, has left her already. The burden of supporting her family, and her strong desire to keep her life going well made her very insecure and anxious. Cross-sectional view of current cognitions, behaviours and biology Two current situations encountered by Kristen will be analysed in this section by looking at her typical automatic thoughts, emotions and behaviours that appear under these situations. The first situation was Kristen attending a meeting at work. She reported having experienced moments of forgetting what she wanted to say in the middle of her sentence because she was too focused on worrying that something disastrous would happen in

the future. Something may have happened during the meeting that triggered Kristen’s worries to such a serious extent that her mind went blank. For instance, Kristen might have seen her colleagues chatting in a low voice and her supervisor frowning while she was talking. She might have automatically jumped to the conclusion that her colleagues did not like her or disagreed with what she said, and that her supervisor was dissatisfied with her performance. All these made her catastrophise the whole situation and her worry about losing her job and becoming homeless resurfaced immediately. At that moment she might be feeling very ashamed of herself for underperforming and at the same time very scared. Some possible physical sensations would be accelerating heart rate and trembling. Mortensen (2014) mentioned that one way anxiety impedes work is that it makes people feel less confident about having effective skills. Anxious people tend to think that they are not capable enough and their performance would be evaluated negatively. Although Kristen’s high performance in the past has led her to a position in the upper level management, she doubted that she could maintain this position and this induced feelings of shame and insecurity. Moreover, according to Bradley, Mogg, White, Groom and de Bono (1999), people with generalised anxiety disorder displayed higher vigilance to threatening faces such as angry faces. Hayes and Hirsch (2007) also stated that those with generalised anxiety disorder adopt an information processing model that selectively attends to threatening information and makes threatening inferences, especially in ambiguous situations. This could explain the hypothesis made above, which proposed that Kristen’s anxiety was triggered by the behaviour of other colleagues and supervisors at the meeting. The second situation is Kristen checking the details of her work. It is said that she has been spending an unreasonably long period of time going over her work repeatedly, which made her miss deadlines and work overtime at home. Kristen may have the past experience of still committing mistakes even though she had checked her work carefully, and since then, she has become extremely worried about being careless and not detailminded enough, as this could mean that she is not competent enough to fill her current position. Therefore, every time after finishing her work, she will probably think that “there must be something wrong with what I have done, it is just that I have not yet found it”. Consequently, Kristen would not give up proofreading until she found a tiny mistake or until she was satisfied with the number of times she checked her work. Her emotions would include nervousness, frustration and worry. Some possible physical sensations could be chest tightness and shortness of breath.

Generalised anxiety disorder is associated with the belief of “nothing is ever good enough” (Peterson, 2014). Indeed, Shafran, Egan and Wade (2010) suggested that perfectionism is linked to anxiety. They also reported that people with perfectionism commonly engage in performance-checking behaviour, yet this kind of unhelpful, extreme behaviour rarely make people feel satisfied. Victoria Maxwell, a famous speaker and educator that suffered long from generalised anxiety disorder and other mental illnesses, mentioned that she always engaged in critical self-talk, doing a mantra like “it’s never good enough… it’s never good enough” repeatedly in her mind while she was working (Maxwell, 2012). From this, it is hypothesised that Kristen might be deeply affected by perfectionism, a kind of by-product of generalised anxiety disorder, and so she developed the habit of constant and excessive performance-checking when she was at work. Longitudinal view of cognitions and behaviours Two possible developmental antecedents are suggested here. Firstly, Kristen’s father was laid off work during her childhood days and struggled to find work again ever since. This probably meant that Kristen’s family had experienced financial problems before, which might have influenced Kristen’s view on the importance of maintaining a stable career, and further intensified her worry about losing her job after the divorce. She would definitely not want to repeat this struggle again in her own life and let her family suffer, because she knew how hard it is to go through it. Secondly, Kristen described her mother as being “too involved” in her life. Having to go through a divorce is already very stressful; being constantly monitored by a highly intrusive parent may add huge stress to Kristen and elevate her anxiety to a higher level. This might also influence Kristen’s own parenting style, resulting in her constantly checking on her children and being too involved in their lives. Strengths and Assets Kristen has a well-paid, stable job in a thriving company, meaning that her career prospects will likely be quite good. She also has two children who expressed concern over her conditions and would like to be more supportive to her.

Working hypothesis The fact that Kristen’s father struggled to find work after being laid off during her childhood predisposed Kristen to be very concerned about maintaining her job. She could picture all the hardships she and her children will have to go through if she loses her job. The stress imposed on her by her intrusive mother may have accumulated over a long period of time and eventually contributed to the onset of anxiety. The main precipitant is Kristen’s recent divorce, which may have caused a great amount of self-doubt and self-blame. These negative feelings have spilled over to her work life, making her constantly unconfident in her ability and suspecting that she might lose her job. The unstoppable worrying thoughts impaired her attention and interpretation of ambiguous situations. They also triggered the onset of perfectionist thoughts, impairing her work efficiency. Kristen has social support from her children, but clearly her interference with their lives made them uncomfortable. They are unsure about how to help her because of this. III.

Treatment Plan

Problem List Kristen has excessive worries about her work and her ability to support the family. Her mind was filled with negative, catastrophising thoughts such as losing her job and ending up homeless. She has been feeling restless, tired and tense all the time. She could not concentrate and work efficiently. Her brain would not shut off at night, always visualizing worst-case scenarios and so she suffered from poor sleep. Treatment goals and moderation/mediation Cognitive Behavioural Therapy (CBT) is recommended as treatment. The suggested long-term treatment goals are (1) reduction in overall frequency and intensity of anxiety such that her occupational functioning, relationship with her children and sleep quality will improve; (2) modification of dysfunctional thoughts and beliefs about herself and events and (3) learning and adopting techniques that can help her better cope with stress.

The suggested short-term treatment goals are (1) focusing on one task at a time on the to-do list; (2) completing tasks at work punctually by shortening the time used on proofreading (3) checking on her children for not more than three times a day and (4) exercising for 30 minutes at least three times a week. Threat reappraisal may be one of the mediators of treatment, although so far studies mainly focused on threat reappraisal being the mediator of treatment to panic disorders and social anxiety disorder but not generalised anxiety disorders (Smits, Julian, Rosenfield & Powers, 2012). On the other hand, anxiety sensitivity may be a moderator. Wolitzky-Taylor, Arch, Rosenfield, and Craske (2012) discovered that pre-treatment levels of anxiety sensitivity is a moderator of CBT’s treatment response. Intervention In Kristen’s case, cognitive restructuring should be one of the main elements in therapy. It is evident that she has cognitive distortions, such as catastrophising and arbitrary inferences. Requiring Kristen to complete thought records every week might be desirable. She would be encouraged to fill in the thought record whenever an anxious thought floats in her mind. She has to record the trigger of that thought, the exact cognitions and emotions that run through her mind, counter-argument to that thought, alternative viewpoints and finally conclude with a rational response to the situation. Thought records help patients to recognise their negative automatic thoughts, identify thinking errors and challenge their thoughts from different perspectives. This will eventually lead to a modification of dysfunctional beliefs and so when the patient encounters similar situations, he/she will know how to cope with it effectively. Behavioural experiments could be carried out too. For example, if Kristen used to check her work 10 times before submitting it, she would be encouraged to try checking it for at most 5 times before submitting it and see how it goes. If the result is satisfactory, she will understand that she overreacted to the situation and she is actually capable of doing good work. Another example would be encouraging Kristen to talk to her colleagues and supervisor about her performance. Given that she has a successful career, the reassurance from co-workers may help her regain confidence. Practising relaxation techniques with Kristen during therapy sessions may be useful too. Since muscle tension is a very common physical symptom of anxiety patients, learning

about progressive muscle relaxation would be beneficial. One of the main exercises in this relaxation technique is contracting a certain muscle group while inhaling and relaxing them while exhaling, and repeating this process for different body parts. This will help the patient to be aware of muscle tension when it happens and notice the difference between tense and relaxed muscles (McNeil & Lawrence, 2002) Grover and Nangle (2002) suggested that the best reatment for generalized anxiety disorder combines cognitive, behavioral, and physiological elements. The above treatment plan encompasses all these aspects, which should be able to achieve the aforementioned treatment goals. Obstacles One possible obstacle would be the patient’s attitude towards the process of the therapy and expectations on the outcome. If Kristen has initial thought that the therapy will be ineffective, there may be self-fulling prophecy and she will put less effort. If she accepts therapy simply because she is forced by others, she will have less motivation and may not adhere to the homework requirements of the therapy. If she expects that the therapy will bring huge improvement to her conditions in a very short time, she may find the progress less encouraging than she thinks and becomes less motivated. She may ignore the small improvements she has made too. Another obstacle would be her relationship with the therapist. If Kristen is unable to develop a trusting relationship with her therapist, it would be difficult for her to open up and discuss her problems.

References American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC. Retrieved from https://books.google.com.hk/books?hl=en&lr=&id=JivBAAAQBAJ&oi=fnd&pg=PT18&dq=dsm5&ots=ceOM_2JHsf&sig=gSViBcLvqp9BhZqD1n_JJ2erKqg&redir_esc=y#v=o nepage&q=dsm-5&f=false Booth, A., & Amato, P. (1991). Divorce and Psychological Stress. Journal of Health and Social Behavior, 32(4), 396-407. Bradley, B. P., Mogg, K., White, J., Groom, C., & Bono, J. (1999). Attentional bias for emotional faces in generalized anxiety disorder. British Journal of Clinical Psychology, 38(3), 267-278. doi:10.1348/014466599162845 Grover, R. L., & Nangle, D. W. (2002). Progressive Relaxation. Encyclopedia of Psychotherapy,401-407. doi:10.1016/b0-12-343010-0/00168-9 Hayes, S. & Hirsch, C.R. (2007) Information processing biases in generalised anxiety disorder. Psychiatry, 6, 176-82 Maxwell, V. (2012, January 19). The Vicious Triangle of Perfectionism, Anxiety & Depression. Retrieved November 28, 2017, from https://www.psychologytoday.com/blog/crazy-life/201201/the-vicious-triangleperfectionism-anxiety-depression McNeil, D. W., & Lawrence, S. M. (2002). Relaxation training. Encyclopedia of Psychotherapy,515-523. doi:10.1016/b0-12-343010-0/00182-3 Mortensen, R. (2014). Anxiety, Work, and Coping. The Psychologist-Manager Journal, 17(3), 178-181.

Peterson, T. J. (2014, May 8). The Link between Perfectionism and Anxiety. Retrieved November 28, 2017, from https://www.healthyplace.com/blogs/anxietyschmanxiety/2014/05/the-link-between-perfectionism-and-anxiety/ Shafran, R., Egan, S., & Wade, T. (2010). Overcoming perfectionism: a self-help guide using cognitive behavioral techniques. Retrieved from

https://books.google.com.hk/books?id=Q6SeBAAAQBAJ&printsec=frontcover& source=gbs_ge_summary_r&cad=0#v=onepage&q&f=false Sharma, B. (2011). Mental and emotional impact of divorce on women. Journal of the Indian Academy of Applied Psychology, 37(1), 125-131. Retrieved November 27, 2017, from http://jiaap.org/listing_detail/logo/5fd3f8b2-9fb6-4934-9c1f0ab50f31ea09.pdf Smits, Jasper A. J., Julian, Kristin, Rosenfield, David, & Powers, Mark B. (2012). Threat Reappraisal as a Mediator of Symptom Change in Cognitive-Behavioral Treatment of Anxiety Disorders: A Systematic Review. Journal of Consulting and Clinical Psychology, 80(4), 624-635. Wolitzky-Taylor, Kate B., Arch, Joanna J., Rosenfield, David, & Craske, Michelle G. (2012). Moderators and Non-Specific Predictors of Treatment Outcome for Anxiety Disorders : A Comparison of Cognitive Behavioral Therapy to Acceptance and Commitment Therapy. Journal of Consulting and Clinical Psychology, 80(5), 786799. Grade: A-

Accurate diagnosis is made in the case analysis. However, you should have pointed out that GAD worry excessively about diverse subjects without a persistent focus on any one thing. You have mentioned that GAD is pervasive, and the uncontrollable quality of worry that makes it the hallmark of GAD and the true distinguishing feature of this disorder. Such constant, diffuse worrying leads to chronic feelings of anxiety. This paper has identified and demonstrated an accomplished understanding of most of the issues/problems. You have supplemented the case analysis with relevant and thoughtful research to support your intervention design. However, explain how you prioritize the target problems to be treated in the intervention regime....