Cbt Formulation for Anxiety

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A. FORMULATION

Presenting Problem
Lara is eight years of age, is the eldest of three children and the only one at school. Shehas presented with a range of problems. She has strong beliefs such as “I must do my best”, “I must not offend my teacher, parents or friends”, and “I must keep out of trouble”. These thoughts cause her to become terrified at just the thought of school, resulting in physiological symptoms such as heart palpitations and sweaty hands. Lara has been experiencing nightmares of monsters surrounding her in the school grounds. These images increase her avoidance of getting up the next morning, especially if it is school morning. Lara has been finding it increasingly difficult to get into the car to attend school, where she sobs and whimpers for the 20-minute trip. Lara is terrified of school. Her peers, who take her pencils and eraser and call her a “four-eye midget”, are bullying her. This isincreasing her dread of attending school.

Lara is not doing well at school. She is unable to add/subtract and has difficulty with Grade 2 reading. Lara perceives hers parents as being strict on her, demanding she achieve straight ‘A’ grades scolding her and comparing her to her cousins when she does not reach their standard. Additionally, the teacher is perceived as being strict on the children’s performance within the classroom, reprimanding when necessary. They have had previous attempts to find a solution to these problems by seeing the school counsellor. The morning rituals of getting Lara ready for school and dropped off is taking a toll on the family as a whole.

It seems that her thoughts and physiological symptoms are triggers. Other triggers are: the car which is modified by whether it is a school day, the teacher which is modified by students getting into trouble, the classroom which is modified by getting reading or math incorrect, school mornings which is modified by the experience of nightmares, and her parents which is modified by them arguing. Lara’s strengths: has a good relationship with her siblings. Has respect and thought for others. Likes to be creative and draw. However, she finds it hard to concentrate and remember things.

Predisposing Factors
Lara is short-sighted. Her speech was delayed (to age 4 years). Her parents have a perfectionist type parenting style. There may be some possible biological pre-dispositions and genetic vulnerabilities in regards to perfectionism, coping skills, dread, fear and worry. Being the eldest child may impact her role in the family and be part of the reason why her parents have such high expectations of her grades.It seems that Lara’s academic performance has declined since entering Grade 2, however the possibility of a learning deficiency requires further exploration, along with confirming that her prescription glasses are suitable for her eyes. Lara has no friends her own age, the ones she does have are younger than her.The two environments in which she spends most of her time, home and school, are strict and demanding. School is also very intimidating as she is being bullied regularly. It is unclear at this point when this first started.

Precipitating Factors
It is unclear what exactly precipitated the onset of these problems. Entering Grade 2 may have been the catalyst, as she did not have difficultiesin Grade 1. It may also be as specific as not keeping up with the reading or making mistakes with her adding/subtracting in class that caused these problems now. Ongoing bullying has also been a precipitating factor. Perpetuating Factors

There are a number of factors that are contributing to the maintenance cycle. Lara’s negative automatic thoughts, images and assumptions ignite her feelings of fear, sadness, anxiousness, worry and apprehension. This further provokes her physiological symptoms of a racing heart and sweaty hands. Lara’s lack of awareness around these body sensations and where they come from would further...
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