Jim is a 37 year old man who is suffering from various problems, such as anxiety, depression and poor sleep. He is also living alone in his apartment but has two daughters who live away from home. He has been working in a factory but is off long term because of his anxiety and depression. His current problems include thoughts of harming himself and worrying. When he is in public he has also reported that he wants to return home where he feels safe which could be due to feeling hot and sweaty, therefore he finds it difficult going into public places, which could be making a social life difficult for Jim. This could be causing Jim’s depression as he is becoming increasingly lonely and could be ruminating. Jim’s thoughts, feelings and behaviours are contributing to a vicious cycle. By addressing Jim’s difficulties with anxiety and fears, Jim may be able to feel safe whilst going into public places which, in the future, could allow him to attend work, therefore reducing his depression as he has less opportunity to ruminate. Therefore this case formulation will concentrate on Jim’s fear of leaving his home (agoraphobia) and what others think of him whilst he is in public (social phobia). By addressing these issues, his thoughts of harming himself, depression and his sleep problems will be indirectly addressed.
The conditional approach to anxiety and agoraphobia suggested that fear was thought to be the central component which gives rise to avoidance behaviour. Research found that 81% of participants attributed onset of agoraphobia to a conditioning experience (Ost & Hugdahl, 1983). Further research found that the thought process in agoraphobia was associated with what may happen to them in public but not always after a fearful event (Klein, 1987). Therefore the formulation for the therapy has been based on the cognitive behaviour approach (CB) first developed by Beck (1976). The CB approach suggests that feelings, thoughts and behaviours are all linked and can create a continuous cycle which one can find difficult to escape. This system is multidimensional and can create a loop where behaviours may affect feelings, cognitive behavioural therapy (CBT) aims at interrupting the cycle. Therefore the model which will be used for this case formulation is the Clark and Wells (1995) model of social anxiety. This model is based on Clark’s (1986) original model but includes processes which will contribute to the persistent cycle. These processes are self-focussed attention and forms of avoidance and safety behaviours. These processes demonstrate how a cycle can continue if the safety procedures and thoughts are not challenged. The formulation is based on the model of social anxiety which demonstrates the cycle of anxiety and fear which Jim is feeling. It is hypothesised that Jim is suffering from agoraphobia because he fears public places and it is often associated with other psychological problems, with Jim these are social anxiety and depression.
Based on the idea that Jim has agoraphobia with social anxiety, this formulation will demonstrate the cycle of his disorder using Clark and Wells (1995) model for social phobia (Figure 1.)
Step 1 – A social situation activates an assumption within Jim. For Jim the social situation is a public place, he then may fear that something could happen to him which could be discovered by asking “are you afraid of something happening and if so what?” This fear could cause him to feel a sense of social danger.
Step 2 – This assumption could lead him into perceiving a sense of danger in the form of social judgement, because he worries about what other people think of him as he believes that they are staring at him and think he is weird. All of Jim’s attention will become internal as he starts to notice his own sensations and thoughts, resulting in self-focussed attention.
Step 3 – A perceived sense of danger can then lead to sensory and cognitive symptoms; trembling, feeling hot and sweating. Jim believes that other people can see the sweat and claimed that “it’s pouring down my face” even though the therapist could not see the sweat that Jim was suggesting. Jim may be focusing his attention on himself, noticing his symptoms which he perceives are producing a bigger impact. These somatic and cognitive symptoms create a cycle with the way he processes himself as a social object. Jim could be afraid of what may happen to him in a public place which contributes to his belief that he is being stared at and is under pressure from other people. This then causes him to experience symptoms such as trembling and feeling hot, finally this stage links back to perceiving himself as looking weird to others which influences the perceived social danger.
Step 4 – Another cycle included within this model is that with safety behaviours of returning home which comes from the perceived social danger. This safety procedure then links into somatic and sensory symptoms, which for Jim is the reduction of feeling hot and sweaty. He may have other safety behaviours which could be found by asking “are there any other methods you use to decrease your anxiety”. This process, links back to the processing of self as a social object.
Step 5 – A final cycle which could be contributing to Jim’s social anxiety is that the safety behaviour of staying at home may allow him to think he is only safe when he is at home. This links back to the social assumption that if he is in public that something may happen to him, which links into the social danger of being judged and being under pressure. This situation can then link back to the social situation.
Public PlaceTherefore Jim’s agoraphobia with social anxiety disorder is a continuous circle with many loops which inter-relate.
Fear that something will happen
Perceived Social Danger
Being stared at and thought of as weird
Processing of Self as a Social Object
Image of self as sweating and looking weird.
Somatic and Cognitive Symptoms
Shaking, Hot, Sweating
Going Home, Biting Nails.
Figure 1. A Cognitive Behavioural Therapy Model of Jim’s Agoraphobia with Social Anxiety based on Clark and Wells (1995) Model for Social Phobia.
To test whether the proposed hypothesis is correct and therefore provide efficient treatment for Jim then more information will be needed. One method of testing that Jim has social anxiety is by using the Liebowitz Social Anxiety Scale (LSAS) (Liebowitz, 1987). This measure assesses social anxiety within different situations, through a self reporting method which Jim may feel more comfortable producing rather than talking to the therapist during early stages of therapy and is as achievable 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 social anxiety (Rytwinski, Fresco, Heimberg & Coles, 2008).
Assessment is needed of fears because agoraphobic patients are thought to be afraid of what may happen to them in public settings. The Agoraphobic Cognitions Questionnaire (ACQ) is a self reporting method which examines three dimensions; fear of bodily in-capitation, fear of losing control and fear of acting embarrassing (Hoffart, Friis & Martinsen, 1992). It has been found that those who have agoraphobia with social phobia rate highest on the fear of acting embarrassing, therefore it is expected that Jim should rate highest on this scale. Another issue is to find out where the agoraphobia stems from; therefore questions about his past will be relevant, to find how the initial fear has developed. It is common for people with agoraphobia to have developed their problem when a close family member has deceased and are in bereavement during the onset (Rachmen, 2004). Jim’s wife may have deceased and therefore may have developed his agoraphobia during bereavement as he may now have a fear of death or illness.
Some people develop agoraphobia after a fearful event therefore previous life experiences could have produced his onset, and could be measured by using the Life Experiences Survery (LES) (Sarason, Johnson & Siegal, 1978). The LES has been designed to examine life experiences and coping methods. This would be useful for Jim to see if there was a specific trigger which he did not deal with effectively.
It is possible that because Jim feels he is unable to be in public, he does not feel a sense of control over his life; this could explain the depression, as a low sense of control is associated with depression (Cash, 1984). Overall it is thought that Jim’s safety behaviour of staying in causes him to ruminate, which could be contributing to his depression.
A final issue for assessment with Jim would be to examine his mental imagery. Jim seems to be concerned with how others perceive him and thinks they can see his symptoms. These mental images are a key role in maintaining his social anxiety (Hirsch & Holmes, 2007). A method to assess Jim’s imagery would be through the Social Phobia and Anxiety Inventory (SPAI). This measure assesses specific somatic symptoms, cognitions and behaviours across a wide range of fearful situations (Turner, Beidel & Dancu, 1989). The SPAI can determine whether Jim has social phobia alone, agoraphobia alone, or a combination.
All of these measures would be useful for Jim so that his processes and beliefs can be clarified. This is important to achieve for client-therapist relationships. If Jim does not feel the therapist understands him, then he may not want to proceed with therapy.
Firstly Jim will need to understand the formulation which has been developed and understand how this will help him to get over his anxiety and phobia of being in public. Therefore Jim can guide the therapy and where he would like to focus his main concerns, which could be his sleep problems and thoughts of harming himself.
The treatments which may be most helpful for Jim are to challenge his negative thoughts. Jim will need examples of how thoughts relate to bodily sensations, and how thoughts themselves can cause the bodily sensations. Therefore by conducting a test such as reading out symptom words and Jim examining the effects of the words, he will see how thoughts can cause bodily reactions.
Another method which could be of use to Jim is that of role play (Anthony & Swinson, 2000). He could pretend he is in a public setting with the therapist whilst he is being filmed. After the role play he could watch the video which would demonstrate that the sweating is not as visible as he thinks. This would allow Jim’s internal perceptions of himself to be challenged and to reattribute his thoughts. If this is successful Jim’s anxiety in public could reduce as he may realise there are no reasons for people to “stare at him and think he is weird”.
A method which could follow is graded exposure (desensitisation therapy). This is achieved by having Jim participate in activities which exposes him slowly to anxiety provoking situations with the activities and pace set by Jim. Therefore he may go to his front door, the following week he will go to his garden/road, this may increase his anxiety so he will need to perform this on several occasions till he realises that there is nothing to fear. Each activity is created to expose him to anxiety which is increased from the last activity, and only when this anxiety decreases does he need to proceed to the next goal (Edelman, 2002).
One issue where therapy could be less successful is if it took place at the office. This may cause problems for Jim as he feels anxious when in public. Therefore, therapy would be more successful if it took place at Jim’s home during the beginning of therapy. This would cause him less anxiety and more willing to participate in therapy and allow for exposure to the public to happen slowly. Expecting quicker results than Jim is able to cope with will cause a poor client-therapist relationship, which could result in Jim’s reluctance to attend therapy. It is important to build up a good client-therapist relationship because those with social phobia often find it difficult to talk about personal issues (Veale, 2003).
Overall the treatment should reduce his agoraphobia and social anxiety, making him feel safe outside of his own