Assessment ends with the development of an idiosyncratic version of the cognitive model. In particular, therapists aim to show patients how the specific triggers for their anxiety produce negative automatic thoughts relating to feared outcomes and how these are maintained by safety behaviours and other maintenance processes.
The model is usually drawn on a whiteboard, so that patient and therapist can look at it and discuss it together. Figure 1 shows an example for a panic disorder patient. His panic attack started with a twinge in his chest muscles, and he then had the thought, 'There is something wrong with my chest area, maybe I am having a heart attack'. This interpretation made him start to feel anxious, his chest muscles tightened up more, he started to feel dizzy, his heart raced more, and he then thought, 'I'm dying, I'm having a heart attack', and also, interestingly, 'If I don't die, people will notice I'm anxious and think it is odd'. He then engaged in a series of safety behaviours to try to prevent himself from dying. He thought he had read somewhere that paracetamol (aminacetophen) is good for people with heart problems and so he took a paracetamol. This is incorrect information, but the key point is that he believed it. He also sat down and rested, took the strain off his heart, and took deep breaths, trying to slow down his heart rate. He believed that the main reason he had not died was that he had engaged in the safety behaviours. The reader will also notice that some of the safety behaviours (taking deep breaths and monitoring the heart) will also have augmented his feared symptoms.
Fig. 1 A cognitive model of a patient's panic attacks. (Reproduced with permission from D.M. Clark (1996). Panic disorder: from theory to therapy. In Frontiers of cognitive therapy (ed. P.M. Salkovskis), pp. 318-44. Guilford Press, New York.)
Figure?, shows a further example with a social phobic patient. The patient's main fear was that other people would think she was stupid and boring. The situation used to develop the model was a recent coffee break at work during which the patient had difficulty joining a conversation with colleagues. When attempting to join the conversation she had the thought, 'I'll sound stupid and everyone will think I am dumb'. In order to prevent herself from sounding stupid, she engaged in an extensive set of safety behaviours which (a) prevented her from discovering that her spontaneous thoughts are interesting to other people, (b) made her appear preoccupied and uninterested in her colleagues, and (c) made her excessively self-conscious. While self-conscious, she became particularly aware of anxiety symptoms (sweaty palms, stiff muscles around her mouth) that she thought other people might see, and indeed, had an image of herself in which she looked very strange, with a twisted and rigid mouth and appeared stupid.
Normally idiosyncratic models of the form illustrated in Fig 2 and Fig, 3 will be developed at the end of the first interview, and certainly not later than the second session. Such models are used as blueprints to help therapist and patient organize and develop the rest of therapy.
Fig. 3 Distribution of chest pain in patients referred to a cardiac clinic and subsequently diagnosed as non-cardiac chest pain (NCCP), angina pectoris (AP), or myocardial infarction (MI). (Reproduced with permission from R. Beunderman et al. (1988). Differentiation in prodromal and acute symptoms of patients with cardiac and non-cardiac chest pain. In Advances in theory and practice in behaviour therapy (ed. P.M.G. Emmelkamp et al.). Swets and Zeitlinger, Amsterdam.)
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