Cognitive Assessment and Case Formulation 159
attacks had limited interference in her daily functioning. Thus it was concluded that
treatment of panic attacks that were not related to her social anxiety was not warranted
at this time.
Assessment of Immediate Fear Response
Sharon listed a number of situations that trigger her anxiety at work. These include
speaking up or interacting in a small group meeting, talking to persons in authority
like her supervisor, one-to-one interaction with work colleagues over their computer
problems, and initiating phone calls at work. These activities were associated with mod-
erate to severe anxiety and a moderate level of avoidance. Given that her job primarily
involves consultation with others, Sharon was frequently confronted with these anxiety-
provoking situations on a daily basis. Other social activities that triggered consider-
able anxiety and avoidance were going to parties and being assertive, especially refus-
ing unreasonable requests. Sharon completed a Situational Analysis Form as part of a
homework assignment and reported a number of anxious episodes focused on small
meetings and one-to-one interaction at work. The only cognitive trigger to anxiety was
the anticipatory thought “I must speak to my supervisor about this problem.” It was
decided to target her anxiety in small meetings and one-to-one interaction with work
colleagues since these represented the main triggers to her anxiety.
Two main automatic apprehensive thoughts became apparent from Sharon’s self-
monitoring homework assignments and subsequent interview sessions. When anticipat-
ing or first encountering a social situation at work, Sharon would think “I hope I am
able to perform okay” and “I hope my face doesn’t turn red.” The only physiological
sensations she reported when anxious was feeling warm and her face turning red (i.e.,
blushing). Blushing was a major concern for Sharon. She interpreted this as a sign that
she was anxious, losing concentration, and would be less able to speak clearly and sen-
sibly to others. She was also concerned that people would notice that her face was red
and wonder what was wrong with her.
As a result of these anxious cognitions and the negative interpretations of blushing,
Sharon exhibited a number of automatic defensive responses. Behaviorally she would
say as little as possible in meetings (i.e., avoidance) and would speak very rapidly when
she was forced to interact with others (i.e., escape response). She avoided eye contact
in her social interactions. She also was hypervigilant about feeling warm and would
often touch her face or check in a mirror to determine if she was visibly red. Her main
automatic cognitive defense was to reassure herself that everything was okay and to try
to relax. In sum her primary automatic defensive response to ensure safety was to say
as little as possible in social situations, to avoid eye contact, and to locate herself in a
setting so as to draw as little attention as possible.
A number of cognitive errors were evident in Sharon’s anxious thinking about social
situations. Catastrophizing was apparent in her belief that having a red face was highly
abnormal and something that others would also interpret as a sign of abnormality. She
was also convinced that once her face turned red, it meant she was anxious and would
lose her concentration. This would result in poor performance, which others would
evaluate as social incompetence. Tunnel vision was another cognitive error since Sharon
would often become preoccupied with her face and whether she was feeling warm in
social settings. She also engaged in emotional reasoning in that feeling uncomfortable