Cognitive Assessment and Case Formulation 139
tant to determine if there are any particular bodily sensations that make clients feel
more anxious. Although interoceptive cues to anxiety are particularly evident in panic,
they will be present in all of the anxiety disorders (Antony & Rowa, 2005). For exam-
ple, a person with social phobia might become even more anxious in a social setting if
she begins to feel warm because this is interpreted as a sign of increased anxiety that
might be noticed by others.
The therapist should include questions in the clinical interview about interoceptive
cues (see Table 5.1), but many clients have even less insight into the presence of physical
triggers to anxiety than they do to external cues. A self- monitoring checklist of physical
sensations, such as the form in Appendix 5.3, can be assigned as homework in order
to gather more accurate information on interoceptive triggers. An interoceptive expo-
sure test is another useful strategy for assessing the physical triggers of anxiety. Taylor
(2000) describes a number of exercises that can be used in the therapy session to induce
physical sensations. For example, the client can be asked to breathe through a straw or
jog on the spot to induce chest tightness, to tense muscles to induce trembling/shaking,
or to face a heater to feel bodily sensations of warmth. Although the intentional induc-
tion of such sensations can not be equated with the spontaneous occurrence of these
sensations in vivo, they give the therapist an opportunity to directly observe the client’s
reaction to the sensations.
Cognitive Triggers
Unwanted and disturbing intrusive thoughts, images, or impulses are an example of a
cognition that can trigger anxiety. Practically everyone experiences unwanted mental
intrusions and they are commonly found in all the anxiety disorders. First described by
Rachman (1981) within the context of OCD, unwanted intrusive thoughts, images, or
impulses are “any distinct, identifiable cognitive event that is unwanted, unintended,
and recurrent. It interrupts the flow of thought, interferes in task performance, is associ-
ated with negative affect, and is difficult to control” (Clark & Rhyno, 2005, p. 4). Some
examples of common intrusions are “unprovoked doubt about locking the door when I
know I did,” “touching something gross and dirty that is lying on the street,” “saying an
insulting or embarrassing remark for no apparent reason,” “blurting out an obscenity in
a public meeting,” “swerving your car into oncoming traffic,” and the like. Unwanted
intrusions are very common in OCD as obsessions and in PTSD as sudden recollections
of a past trauma. However, they can also occur in GAD as a negative consequence of
excessive worry (Wells, 2005a) or as unwanted cognitions in the presleep phase of indi-
viduals suffering from insomnia (Harvey, 2005). Unwanted intrusions often involve the
theme of losing control that leads to a dreaded negative consequence.
It is important that the cognitive therapist inquire about unwanted intrusive
thoughts. Table 5.1 lists some possible questions for assessing this clinical phenomenon.
With the exception of OCD or PTSD, individuals are often not very aware of their
intrusive thoughts. A list of common unwanted intrusions can be used and clients asked
if they ever had any of these thoughts, images, or impulses (lists can be found in D. A.
Clark, 2004; Rachman & de Silva, 1978; Steketee & Barlow, 2002). Since most intru-
sions are provoked by external cues, clients can be asked to be especially vigilant for
mental intrusions when in situations that typify their anxious concerns.