Cognitive Assessment and Case Formulation 137
Situational Analysis
A cognitive case conceptualization of anxiety must begin with a thorough assessment of
the situations, experiences, and cues that trigger anxiety. The cognitive therapist could
begin at the most general level by asking about the problems or difficulties that led to
a decision to seek treatment. With the anxiety disorders, the development of a Problem
List (see Persons & Davidson, 2001) will inevitably lead into a discussion of the situa-
tions that trigger anxiety. Three types of situations should be assessed (see also Antony
& Rowa, 2005). Table 5.1 presents a number of clinical questions that can be asked in
the assessment interview.
Environmental Triggers
Information on the external or internal cues, situations, or experiences that trigger a
state of fear or anxiety is a critical part of an evidence-based assessment strategy for the
anxiety disorders (Antony & Rowa, 2005). It is important that the cognitive therapist
obtain a comprehensive list of anxiety- provoking situations with sufficient detail to fully
understand the specific cues that trigger an anxious response. In practically all cases,
objects, events, or situations in the external environment can be identified that trigger
anxiety. Examples of anxiety- eliciting situations include a variety of social settings or
interactions in social phobia, in GAD daily events involving some degree of uncertainty
or possibility of negative outcome (e.g., going on a trip, scheduling an appointment,
paying bills), or in OCD situations that elicit fear of contamination or doubt would be
prominent (e.g., washroom, sitting on park bench). Since a comprehensive knowledge of
anxiety- eliciting situations is critical to case formulation, treatment planning, and later
exposure interventions, the therapist should complete a broad list of triggering situa-
tions that range from the mild to most severe anxiety- arousing triggers.
The cognitive therapist can obtain initial information on environmental triggers
from the clinical interview by asking specific questions about the types of situations that
elicit anxiety (see Table 5.1). However, most anxious clients have selective and inaccu-
rate recall of their anxiety- provoking situations so daily self- recording forms should be
assigned in the early phase of treatment. Appendix 5.2 provides a Situational Analysis
Form that can be used to collect key information on provoking situations. In some cases
where there has been a long history of avoidance or where the client’s self- report may be
unreliable, it may be necessary to interview a spouse, close friend, or family member to
obtain more complete information on provoking situations. The therapist could accom-
pany the client to particular situations or set a homework assignment that involved
exposure to a situation in question in order to assess its anxiety- eliciting properties.
However, this might be too threatening for many anxious individuals, especially in the
early phase of treatment.
Interoceptive Triggers
Most anxious individuals have a heightened awareness and responsiveness to the bodily
sensations that characterize physiological hyperarousal in anxiety. Physiological sensa-
tions such as increased heart rate, feeling warm, lightheadedness, weakness, tension,
and the like can themselves become triggers for elevated anxiousness. Thus it is impor-