Phase 1: Definition of Problems

Given the apparent complexities of the interaction between social anxiety, substance use, HPPD and depression that emerged through the initial assessment session, the need for innovation in exploring and possibly interlinking these problems was evident. This is why a case formulation approach was adopted.

The case formulation process began by asking the client to describe, in his own words, the difficulties he was experiencing. He was encouraged to explain how he saw his problems, not how others (e.g. family, friends and professionals) perceived them. Specific problem statements were sought because they form the foundation upon which the client’s goals of treatment can be operationalized.

Steve identified his presenting problems as ‘visuals’ and ‘social awkwardness’. When asked to describe the visuals, Steve reported:

I’ve had visuals since a trip on acid when I was 15. Things are constantly moving and distorted. Swirls are coming out of the wall behind you right now, and I can see a sort of halo around your head. I hear echoes of conversations from yesterday. I feel like I’m in my own world, separate to everyone else.

Steve identified that his sense of ‘social awkwardness’ developed when he started to experience the visuals and described feeling ‘distanced, dissociated, like I’m constantly trying to make sense of the visuals’. This led him to believe that he did not ‘have anything to contribute to discussions’ and consequently that he would be better off avoiding social situations.

This discussion led to the initial hypothesis that inflexibility of switching attention away from the visuals underlay both of these problems. This hypothesis was tested through imaginary exposure to a social situation, with Steve describing his thoughts and emotions aloud. Steve described how he would try to focus his attention away from the visuals when in social situations by counting items in multiples of five, and that this in itself proved that he was not focusing on the conversation, which led him to focus more attentional resources on his difficulties with maintaining focus on the discussion.

Phase 2: Exploration of problems

Further exploration of the presenting problems through Socratic questioning (Padesky, 1993) facilitated gaining an understanding of Steve’s experiences of the visuals and related sense of social awkwardness through a collaborative, guided discovery. This was of particular importance given the low prevalence and lack of literature regarding HPPD. An alternative hypothesis, regarding the potential of the visuals to ‘override’ cognitive processing rather than them being modulated as a result of attentional flexibility, was eliminated by asking Steve to describe the visuals in one particular situation. It emerged that the visuals could vary in intensity depending on levels of engagement in tasks. Through this exploration, metacognitive beliefs (Wells, 2000) about the dangers and uncontrollability of the visuals were also identified, and the role of focusing attention on the visuals in maintaining them began to emerge. Steve’s metacognitive beliefs centred primarily on the danger and uncontrollability of the visuals, e.g. ‘I’ll be stuck with the visuals, no matter what I do’ and ‘my brain has shut down and I’m going mad’. Positive metacognitive beliefs about the benefits of using alcohol and Clonazepam (Spada, Caselli, & Wells, 2013; Spada, Proctor, Caselli, & Strodl, 2013) were also identified. These included ‘If I drink, then I’ll be able to think more clearly’ and ‘If I use Clonazepam, then I’ll be able to focus’.

The exploration phase also entailed the identification of specific safety behaviours that Steve utilized in social situations. These included counting in multiples of five, nodding, trying to constantly smile and attempting to hide shaking in order to be perceived as comfortable. Steve described how he would view himself as a social object, a concept characterized by the individual’s assumptions that others can observe the manifestation of physiological symptoms of anxiety being experienced, such as hands shaking (Clark & Beck, 2010). The following is an extract of Steve’s description of himself as a social object:

Others can look at me and see what’s going through my mind. I become aware of my lips, I start biting my lips. All of a sudden I become so super-conscious of my lips and how I’m contorting them into all sorts of funny positions. My jaw doesn’t sit right, it’s taking my lips in all funny ways. They feel strange. Rubbery. I can’t take my attention away from thinking how I must appear to others.

Following social situations, Steve would engage in a detailed analysis of how he felt he had behaved in the situation. This rumination was fuelled by metacognitive beliefs about its benefits, including ‘if I ruminate, I’ll figure out what I need to do to come across as more comfortable next time’.

Developmental history

By exploring historical events from the individual’s life, an aetiological perspective of vulnerability to, and development of, presenting problems over time can be gained (Wells, 1997). This understanding is associated with an increased likelihood of successful change (Kirk, 2011) and was facilitated through completion of a timeline of Steve’s life and his psychological difficulties (Figure 8.1).

Steve first noticed that he was becoming anxious around others following the death of his father, when Steve was 11. With family friends referring to him and his brother as ‘the men of the house’, Steve initially felt a sense of ‘macho-ness’ and responsibility for his mother. However, as conflict increased at home and his brother developed depression, Steve yearned to escape from the situation. By taking LSD, he ‘could shut it all out’.

Concurrently, Steve found that LSD helped him to ‘play the joker’ at school, a role that he adopted as he felt ‘unable to hold deep and meaningful conversations’. He used it weekly until the ‘bad trip’ (intoxication), at the age of 15. Steve described how, in contrast to other trips, the hallucinations did not fade gradually over the following week, but remained at the same intensity, with him feeling that he was ‘constantly’ re-experiencing the hallucinations. This led Steve to feel ‘changed’ and ‘socially awkward’, as he felt that he was ‘stuck’ in the hallucinations. Consequently, his social anxiety ‘increased 10-fold’, impacted by the belief that his ongoing experiences of hallucinations would negatively affect how he came across in social situations. To manage this, Steve would avoid social situations or drink in order to feel more comfortable around others.

Steve’s drinking spiralled during a prolonged period of increased stress: his girlfriend experienced mental health difficulties, his business floundered and he learned that he would need to retrain for modern qualifications. Noticing his perceptual disturbances increasing in intensity, Steve researched HPPD on Internet forums and read that taking Clonazepam could aid in reducing his visuals. He bought this online and took it daily for 10 years as he felt it weakened the visuals. Alongside this, Steve would drink to feel more comfortable in social situations. When his girlfriend suddenly left, Steve attributed this to being ‘socially awkward’ and ‘no longer needed’. Consequently, his alcohol and Clonazepam use escalated.

Phase 3: Formulation of problems

Rather than a fixed explanation about a specific problem as offered in disorder-specific protocols, a case formulation draws on cognitive and behavioural principles and practice to offer an idiographic hypothesis about how the individual’s problems developed, how they have been maintained and how they are interrelated (Bruch, 2014; Meyer & Turkat, 1979). Considering its hypothetical nature, the formulation was triangulated through clinical supervision in order to gain others’ perspectives on the appropriateness of the presented hypotheses and possible alternative explanations and thereby reduce therapist bias (Bruch, 2014).

A genetic element indicated by the prevalence of anxiety disorders in Steve’s family may have increased his vulnerability to developing social anxiety (Beatty, Heisel, Hall, Levine, & LaFrance, 2002). Additionally, processes of vicarious learning through observing his relatives’ anxiety and subsequent responses may have led to negative expectancies of social encounters (Bandura, 2005; Davey, 1997). Following his father’s death, a combination of an increased sense of responsibility for his family and the difficult dynamics that developed at home may have contributed to a self-perception of incapability and a desire to ‘escape’ from this situation and related emotions. In response to this, Steve began to use LSD. However, the resulting HPPD led him to feel extremely self-conscious and socially awkward. Steve consequently associated social situations with anxiety through classical conditioning and experienced anticipatory anxiety prior to social encounters. Through avoidance, Steve gained an initial sense of relief (negative reinforcement), which aided the maintenance of the avoidance behaviour.

Worrying about social encounters developed over time through believing that worry would prepare him for unwanted eventualities (Wells, 2009). However, worry came at the cost of heightened anticipatory anxiety and focus on threat (Bar-Haim, Lamy, Pergamin, Bakermans-Kranenburg, & van Ijzendoorn, 2007). Such bias brought a reduction of attentional resources for the situation, increased negative self-appraisal and led to negative anticipation of future events (Clark & Wells, 1995; Rapee & Heimberg, 1997).

Related posts:

The Development of Case Formulation Approaches The Therapeutic Relationship as a Critical Intervention in a Case of Complex PTSD and OCD Cognitive-Behavioural Formulation and the Scientist-Practitioner Case Formulation The UCL Case Formulation Model Generalized Anxiety Disorder

Stay updated, free articles. Join our Telegram channel

Join