Name initials Helen

Gender female
Age 28
Education graduation
Marital status single
Patient Specific Phobia
Source and Reason for Referral .
The physician referred the client due to her symptoms of anxiety.

Presenting Complaints
Table 1
Presenting Complaints according to the client
Complaints Intensity (0-10)

Stomachache 7
Fatigue 9
Loss of energy 9
Drowsiness 9
Clenching of teeth while
sleeping that results pain. 8
disappointed 10
Feel worried and panicky when
thinking about going to university. 10
Loss of concentration 9
Worried about people's criticism 9
Fear of failure 10
Fear of being inadequate at
Studies 10
Melancholic 10
Disturbed sleeping pattern 9

Case Report 1
Identifying data
Behavioral Observation
client looked tense and frightened and could not sit comfortably in her chair. She kept
tapping her feet, shifting her position and she appeared breathless while telling her difficulties.
Unable to maintain appropriate eye contact. She seemed compliant.
Developmental History of the Problem.
Clients financial situation was very bad so she could not decide whether she should continue with
her studies or find a job in order to solve her financial difficulties. Even though Helen felt that she is
suffocating because of all these problems, it seemed that there was no way out since her parents
were ill and she could not leave home. Her parents and sister put too much pressure on her in
relation to her studies. She was pressed and criticized for not being able to continue her studies.
Considering this in combination with the rest "difficult" family environment it comes as no surprise
that Helen developed an anxiety disorder.

Background Information
Personal history. She could not attend the lectures or enter the lecture theatre ("lecture
theatre phobia"). She could not concentrate, study for the exams or sit an exam. She avoided getting
close to the University and she also avoided anything relevant to the University. She was not able to
decide whether she wanted to get her degree or not. She was in a general state of anxiety about
anything. She wanted to be perfect in everything and she worried about other people’s criticism.
She would think about University all the time. Thus, she was not able to enjoy herself and was
always sad. She avoided being with people and finally avoided crowded places.
Family History
Helen was the second child in the family. There was an elder brother (now married) and a
younger sister who had graduated from the law school. There seemed to be many problems in the
family with her brother. He was rebellious and undisciplined – the "problem child" as Helen
characterized him. Helen could not find any means of communication with her family, and her
sister was the only person she really talked to. Her family was a low-income one putting an extra
burden on Helen’s shoulders. Helen felt that as a pupil she was good at everything. However, she
felt that her family shadowed her. They knew anything she did, pressurizing her. The situation at
the time when Helen reached for therapy had as follows:
As it becomes apparent from the above short account of Helen’s family history, her parents and
sister put too much pressure on her in relation to her studies. She was pressed and criticized for
not being able to continue her studies. Considering this in combination with the rest "difficult"
family environment it comes as no surprise that Helen developed an anxiety disorder.

Pre-morbid personality.
She was tended to be sociable, friendly and peacemaker. She was more autonomous before. She is
more reactive to emotions, gets easily emotional.

Educational history. Her sister and father pressed her to continue her studies. They even
wanted her to pursue postgraduate studies. Her father always told her that if she did not finish
University, she would end up being a looser. "If you do not have a degree, you are a zero" he
said. Helen felt that her father counted on her. "He has put me in the place of his son. I always
felt that I had to adhere to what he wanted" she said. Her sister always criticized her calling her
irresponsible. She was also interfering trying to contact Helen’s lecturers to ask them to be more
lenient with her, something that made Helen furious.

The only sector that Helen could function at the time of therapy was foreign languages. She was
good at them and she could study without anxiety. She considered foreign languages a hobby and
not "real work". Surprisingly, her parents were not interested in her performance as far as
languages were concerned, so they did not pressure her.

Occupational history. client's financial situation was very bad so Helen could not decide
whether she should continue with her studies or find a job in order to solve her financial
difficulties. Even though Helen felt that she is suffocating because of all these problems, it seemed
that there was no way out since her parents were ill and she could not leave home.

History of family psychiatry/medical illness. No medical illness history of clients

family.
Provisional Formulation

Assessment
 The assessment was carried out in different dimensions. Following is the list of
assessment techniques which were carried out with the client.
● Behavioral Observation
● Clinical Interview
● Mental Status Examination
● Subjective Ratings
Behavioral observation. . The client looked tense and frightened and could not
sit comfortably in her chair. She kept tapping her feet, shifting her position and she appeared
breathless while telling her difficulties. Unable to maintain appropriate eye contact. She seemed
compliant.
Clinical interview. A clinical interview is a conversation between a clinician and a client
that is intended to develop a diagnosis. It is a "conversation with a purpose" that can be
structured, semi-structured, or unstructured. Emphasis is placed on open-ended questions with
the focus being on the patient and not the clinician. Clinical interviews are used with other
measures and methods to diagnose the patient. There are many different types of clinical
interviews: diagnostic, termination, orientation, selection, intake, case history, and mental status
exams are all examples (Balu, 2015).
Client was greeted with warmth and friendliness, Appropriate eye contact was made
and The discussion on her right to privacy and confidentiality eases client’s mind.
empathetic communication was used. Healthy Rapport building was considered as a
vital component. Relaxed the client by telling about how common anxiety symptoms
are and that there is no shame in seeking help. The therapist’s approach and
discussion of stigma and privacy concerns help her to feel more relaxed and trusting,
and ultimately to open up about her feelings. In diagnostic interview ,It
was made sure that the problem was recognized properly and that the depth of the
problem was
completely unveiled. Effort was made to ask for every major and minor detail that can be
useful for treatment planning.

Mental status examination. Mental status examination was a method for assessing
cognitive and functional impairment of the patient. By assessing metal status of the patient, the
structured data about the functioning of the patient was obtained (Molloy & Standish, 1997).
 Client's MSE revealed her appearance being well dressed, combed hairs and fair hygiene.
She seemed in her conscious state. No obsession, compulsion, delusions, hallucination were
reported and no suicidal thoughts were identified. Her abstract reasoning, orientation, memory,
insight and judgment were intact. However, she got distracted 2-3 times during the interview
during which upon enquiry she reported that he had experienced some thoughts related to other
issue.
Subjective rating. Subjective rating scales are widely used in almost every aspect of
ergonomics research and practice for the assessment of workload, fatigue, usability, annoyance
and comfort, and lesser known qualities such as urgency and presence of any behavior (Annett,
2010). In subjective rating based on any rating that a person gives that is based on their
subjective reaction or opinion, their feelings, desires, priorities. The subjective rating used to
assess the client current level of functioning and rating the client symptoms which helpful to
managed the client behavior need to be managed.
Table 2
Patient’s Symptoms and their Ratings by the Client

Symptoms Ratings (0-10)

Feel worried and panicky when
thinking about going to university 10
Melancholic 9
Perfectionism 8
Loss of concentration
9
Worried about people's criticism
8
Fear of failure
10
Fear of being inadequate at
University
10
Apprehensions about future
9
Avoiding university
Avoiding crowded places 10

Fatigue 9
Drowsiness 9
9
Case formulation
Predisposing factors. Predisposing factors are those that put a child at risk of developing

a problem. As the client has no medical or family history related to anxiety, but
temperamental factor i.e emotional and reactive personality and Environmental factors i.e
shadowing the client's autonomy ,demanding parenting style may act as predisposing factors.

Precipitating factors. Precipitating factors refer to a specific event or trigger to the onset

of the current problem. In this case , her parents and sister pressured her to get a degree
to be worthy she could not decide whether she should continue with her studies or find a job in
order to solve her financial difficulties but there was no way out since her parents were ill and she
could not leave home. , these precipitating factor triggered specific phobia (Exams phobia) in the
client.

Perpetuating factors. Perpetuating factors are those that maintain the problem once it

has become established. Verbal abuse by family about being worthless, less time left
for exams preparation , financial crisis and family’s demand to pursue postgraduate studies acted
as perpetuating factors .

Protective factors. Protective factors are strengths of the child to reduce the severity of

problems and promote healthy and adaptive functioning. In this case, Support from
friends and autonomous personality are the
 protective factors in the current situation of the client.

Suspected problem

According to DSM-5 (American Psychological Association, 2013) the client

was suspected to be with Specific phobia.
Intervention Plan
According to the results drawn from multidimensional assessment of the client the
intervention plan of the client was planned and the goals were identified.
● Rapport was established and maintained with the client to establish therapeutic
alliance with the client.
Establishing and maintaining rapport. Rapport is defined as a ‘harmonious
relationship’ between a client and a therapist (Spink, 1987).
Rapport was established and maintained with the client to establish therapeutic alliance
with the client.
Proposed Management
Goals of treatment

a. Explaining the cognitive model, using Helen’s individual symptoms to illustrate how vicious
circles maintain symptoms
b. Teaching her how to identify automatic thoughts and find alternatives
c. Problem solving concerning studying and sitting exams
d. Becoming able to differentiate from her family

Helen’s assumptions-beliefs:
a. "I am nothing unless I have a degree"
b. "I always have to please my family"
 c. "I cannot cope with the exams"
d. "If I cannot cope with this, I cannot cope with anything"
e. "I always have to do everything perfectly well; otherwise others will look down on me"
f. "I always have to do what my father wants"
g. "Students are snob and I do not want to be like them"
h. "I have to be in control all the time"
i. "If you are used to something, you cannot change"

Helen’s above-mentioned beliefs gave rise to a number of automatic thoughts such as:
a. I cannot get into the lecture theatre
b. I cannot control this matter
c. My parents will never be happy for me
d. It is too late for me to change
e. I have no second chance
f. Everything seems like a mountain
g. I am sick of sitting exams
h. If you have a degree you do not feel inferior
i. No matter what I do this degree will always bother me
j. I do not believe that it is possible to sit an exam and pass
k. My mind is not functioning, I am not going to make it
l. I do not want to be snob like all the other students.

Cognitive distortions

Helen’s main cognitive distortions were stimulus generalization, catastrophizing and selective
abstraction [10]. The range of stimuli that evoked anxiety increased and anything that had to do
with the University was perceived as a danger (stimulus generalization). As many anxious people
[11], Helen tended to dwell on the worst possible outcome. For example, she thought: "If I fail the
exam, I will not be able to finish University and as a consequence I will end up as a cleaner"
(catastrophizing).

Finally, it seemed that Helen was aware of her difficulties in handling the exams situation but not of
her assets. Thus, she had a biased view of the degree both of the danger she was in and of her own
vulnerability (selective abstraction).

Figure 1 shows how the reactions to symptoms maintain the phobia by creating vicious circles that
perpetuate fear. Avoidance maintains anxiety because it makes it difficult to learn that the feared
situation (e.g. exams) is not in fact dangerous, or is not dangerous in the way, or to the extent that
Helen thinks it is. Other important maintaining factors include thoughts, for example about the
meaning of the symptoms of anxiety (e.g. "My brains don’t function properly"), or about the
anticipated consequences of entering the phobic situation (e.g. "I will fail", "I will never be able to
finish University"), and loss of confidence [12].
 b.

c. Figure 1: Helen’s vicious circle Adapted from Butler [12].

Behavioral and cognitive techniques used

"TIC-TOC" technique: Helen could not study because of the negative cognitions she had
concerning studying and University. The therapist focused on these "Task Inhibited Cognitions" and
educated Helen to be able to monitor and challenge these dysfunctional cognitions and substitute
them with "Task Oriented Cognitions" [13]. Thus, Helen’s automatic thought "I am not going to
make it" was substituted with "If I do not try I have no possibility of succeeding, if I do try though I
have at least some possibilities".

"Graded task assignment": The aim of this technique was to maximize the chances of success by
breaking tasks into small, manageable steps [14]. Hence, Helen was given small tasks to carry out.
For example, she would study a few pages each time in order to become able to face this anxiety-
provoking situation (studying).

"Graded exposure": Exposure is defined as facing something that has been avoided because it
provokes anxiety [12]. Helen was encouraged to talk about University and try to visit University.
She thus managed to be able to visit University and even write down the timetable of the exams.
Finally, she managed to go to the lecture theatre to sit an exam with the presence of the therapist at
first and then by herself.

"Daily record of dysfunctional thoughts": Situations that precede unpleasant emotions were

recorded along with the emotions and the automatic thoughts. At a later stage, Helen learned how
to challenge these thoughts (a sample of Helen’s Daily record of Dysfunctional thoughts is given in
Table 1). It should be noted at this point that Helen was not willing to do any homework. This was
considered to be part of her problem since she could not concentrate properly. Thus, the record
forms were completed in the therapeutic session.

Automatic
Situation Emotions Rational Response Outcome
Thoughts
"I am not going to "I am doing well in foreign
Anxious
make it" languages"
Studying for "I do not trust
Satisfaction
the Exams myself" "If I try I have at least some
Scared
"I am afraid to chances of passing"
take the risk"
Table 1: Helen’s daily record of dysfunctional thoughts.