Cognitive Therapy of Anxiety Disorders

Cognitive Assessment and Case Formulation 14 5

response profile when the person is in a state of heightened anxiety? It is important to
determine whether the client typically experiences the same physiological symptoms in
a variety of anxiety- provoking situations. Which bodily sensations are most intense?
Which arousal symptoms are experienced first? How long do they persist? Does the
person do anything to achieve relief from the hyperarousal?
A second question concerns how the state of physiological hyperarousal is inter-
preted. Are there certain bodily sensations that are the primary focus of attention? What
is the client’s concern or fears about that sensation? Identifying the exaggerated threat
appraisal of a particular body sensation is another important source of information on
the core threat schemas that are driving the anxiety. Table 5.2 presents the exaggerated
threat appraisals and schemas that may be associated with a number of physiological
hyperarousal symptoms.
A final question when assessing physiological arousal is their role in the persistence
of anxiety. Catastrophic misinterpretation of physical symptoms plays a key role in
panic disorder (D. M. Clark, 1986a) and hypochondriasis (Salkovskis & Bass, 1997)
but may be less prominent in OCD or GAD. In anxiety disorders where misinterpreta-
tion of physical symptoms is a prominent concern, treatment will focus on “decatastro-
phizing” these exaggerated appraisals. Thus case formulations for anxiety must take
into account the nature, interpretation, and function of physiological hyperarousal dur-
ing the phase of immediate fear.

Clinician Guideline 5.6

The nature, function, and interpretation of physiological hyperarousal and other bodily sen-

sations must be determined as part of any case formulation for anxiety.

table 5.2. exaggerated threat appraisals and schemas that may be associated with Common
physical symptoms of anxiety
Physical sensation Exaggerated faulty appraisal Threat-oriented schema

Difficulty breathing,
shortness of breath

“I can’t breath properly, I feel like I’m

not getting enough air.”

Risk of slow, agonizing death by

suffocation

Chest tightness, pain,
heart palpitations

“Maybe I am having a heart attack.” Death from sudden cardiac arrest

Restless, agitated “I am losing control; I can’t stand this
feeling of anxiety.”

Risk of going crazy, embarrassing

myself, being overwhelmed with

unending anxiety, etc.

Dizzy, lightheaded,
faint

“I might be losing consciousness.” Might never regain consciousness;

cause embarrassment by fainting in

public

Nausea “I might be sick to my stomach;
vom it.”

Suffocate from vomiting;

embarrassment from being sick in

public setting

Note. Based on Taylor (2000).