Cognitive Assessment and Case Formulation 141
a person with fear of contamination first enters a public area, what is first noticed that
elicits some concern, the speck of dirt on the floor or the fact that a stranger just brushed
past him? For a socially anxious individual, does he fi rst notice that his throat feels dry or
that his hand seems to be shaking? A person with PTSD might avoid a particular route to
work because of anxiety but it is really the fact that driving past a particular ethnic store
along the route triggers flashbacks that is the crux of the problem. In addition it is impor-
tant to determine whether the person is hyperviligant for these subtle and specific anxiety-
provoking cues. It is likely that a self- monitoring homework assignment will be needed in
order to identify the salient attentional features of anxiety- provoking situations.
Clinician Guideline 5.4
A complete situational analysis should include detailed information on a wide range of
anxiety- provoking external and internal situations or stimuli, with a specific focus on the
intensity of anxiety, frequency, and duration of situational exposure, extent of escape/avoid-
ance, and presence of eliciting cues.The First Apprehensive Thoughts or Images
One of the main consequences of threat schema activation during the immediate fear
response phase is the production of automatic threat- oriented thoughts and images (see
Figure 2.1). These threat- oriented automatic thoughts and images occur at the earliest
point in anxiety generation and provide a window into the schematic content that is the
basis of the anxiety disorder.
In the context of assessment the cognitive therapist can refer to these initial threat-
oriented automatic thoughts as the first apprehensive thoughts. They are defined as brief,
sudden, and completely automatic thoughts or images that something bad or unpleas-
ant is about to happen, or at least could happen, to persons or their valued resources.
In panic disorder these first apprehensive thoughts might refer to the dangers posed by
a perceived physical sensation, in social phobia it might be the thought of drawing the
attention of others, in OCD it might be of some catastrophe for others as a result of
one’s action or inaction, in PTSD it could be a sense of losing control and increased per-
sonal vulnerability, and in GAD it could be the occurrence of some serious negative life
event. Notice that the first apprehensive thoughts always reflect some important aspect
of the person’s primary anxious concerns. In fact the situational analysis will provide
the therapist some clues as to first apprehensive thoughts because of the types of situa-
tions that provoke anxiety.
Discovering the client’s first apprehensive thoughts presents special challenges for
assessment. Often these thoughts are so rapid and transient that the person only experi-
ences them as a sudden feeling of fear or apprehension. The actual automatic thought
content is lost because it is quickly replaced by more elaborative, reasoned reappraisal
of the situation. So, when the therapist questions clients about their first apprehensive
thoughts, what is recalled and reported are the more deliberate reappraisal thoughts
that occur in the second phase of anxiety. Clients interviewed when not feeling anxious
may dismiss the first apprehensive thoughts as too exaggerated and unrealistic, and so
deny they ever occurred during an anxious episode.