158 ASSESSMENT AND INTERVENTION STRATEGIES
developed within the first two to three sessions, which will then be frequently revised
and elaborated throughout the treatment process. In fact it is this changing, evolving
nature that is the heart of case conceptualization (Persons, 1989).
A diagram of the cognitive case conceptualization of anxiety that is available in
Appendix 5.11 can be used to summarize the assessment information and derive an
individualized case formulation. Although there are many components to case formula-
tion, the clinician is never expected to have a “finalized formulation” before initiating
treatment. Certain core elements of the conceptualization should be apparent after the
initial assessment and prior to treatment such as the situational triggers, first apprehen-
sive (automatic anxious) thoughts, physiological hyperarousal, defensive (i.e., safety-
seeking) responses, primary worry content (if relevant), and coping strategies. These
aspects of the formulation will be revised and other components completed during sub-
sequent treatment sessions. An individualized case formulation, then, evolves over the
course of therapy.
Cognitive Case Conceptualization
We return to the clinical case presented at the beginning of this chapter. Sharon sought
treatment for a long- standing problem with persistent anxiety that manifested itself
mainly while interacting with work colleagues in her employment setting.
Diagnostic and Symptom Assessment
Sharon was administered the ADIS-IV as well as the general anxiety measures discussed
in this chapter. Based on the ADIS-IV her primary axis I disorder was social phobia.
Panic disorder without agoraphobic avoidance was a secondary axis I diagnosis. She
also met criteria for a past major depression, single episode. The depression spontane-
ously remitted after 2 months and occurred in response to the death of a pet. She also
reported a subclinical fear of heights and worry, but the latter was clearly related to her
social anxieties at work. She obtained the following scores on the questionnaire battery;
Beck Anxiety Inventory Total = 6, Beck Depression Inventory–II Total = 12, Hamil-
ton Anxiety Rating Scale = 10, Cognitions Checklist— Depression = 15 and Cogni-
tions Checklist— Anxiety = 7, and Penn State Worry Total = 64. Sharon also completed
the Social Phobia and Anxiety Inventory (SPAI; Turner, Beidel, & Dancu, 1996) and
obtained a Difference Score of 105.9, which is consistent with untreated generalized
social phobia. Thus the psychometric data suggest only mild anxiety symptoms that are
more cognitive than physiological in nature. The Penn State Worry score is elevated, but
this is due to the client’s worry about her social interactions at work. The BDI-II and
CCL-D suggest the presence of some depressive symptoms. A pretreatment average daily
anxiety level of 21/100 again confirmed a rather low level of anxiety.
The diagnostic assessment clearly indicated that the social phobia should be the
primary focus of treatment. Although she met diagnostic criteria for panic disorder,
the initial onset was 15 months ago, with the last full-blown panic attack occurring 1
year ago. In total she experienced four full-blown panic attacks and a number of limited
symptom attacks, with many of the later occurring in social contexts at work. However,
Sharon reported only minimal, brief periods of concern about the panic attacks that
lasted only 3–4 days after a full-blown episode. Sharon also indicated that the panic