lung ventilation during treadmill locomotion in a terrestrial turtle

DEPRESSION AND ANXIETY 25:811–823 (2008)

Theoretical Review

A COGNITIVE BEHAVIORAL CASE FORMULATIONFRAMEWORK FOR TREATMENT PLANNING

IN ANXIETY DISORDERS

Mark J. Boschen, Ph.D.1� and Tian P.S. Oei, Ph.D.2

A cognitive behavioral case formulation framework (CBCFF) for anxietydisorders is presented, in which the etiological and maintaining factors for theanxiety disorders are outlined in a single, simple, visual framework. ThisCBCFF is then used to demonstrate the specific links of different cognitive andbehavioral treatment components to aspects of the case formulation. An exampleis used to illustrate the use of the CBCFF, highlighting its utility with novelpresentations for which no manualized treatments exist. Depression andAnxiety 25:811–823, 2008. & 2007 Wiley-Liss, Inc.

Key words: anxiety; case formulation; cognitive behavior therapy

INTRODUCTIONA case formulation (CF) is ‘‘a provisional map of aperson’s presenting problems that describes the terri-tory of the problems and explains the processes thatcaused and maintain the problems.’’ [Bieling andKuyken, 2003, p 53]. The CF represents the summa-tion of the assessing clinician’s ideas about how theclient’s psychopathology developed and is perpetuated,and evolves over time as further information isdiscovered and incorporated. A client’s CF is used asthe basis for planning interventions aimed at reducingthe impact of causal and maintaining factors in theirpresentation, and reducing enduring vulnerabilityfactors.

There exists a strong general consensus amongpracticing clinicians from all therapeutic schools thatCF is an essential step to providing effective, purposivetreatment, particularly for complex presentations [Eellset al., 1998; Sperry et al., 1992]. A sound understandingof the client’s presentation is a prerequisite fortreatment planning, with the alternative being anunstructured, ad hoc style of intervention.

Case formulations, regardless of the therapeuticparadigm from which they emerge, all share severalcommon elements. Case formulations generallydescribe the client’s psychopathology using an easilyoperationalised vocabulary, providing clear guidance intreatment, and evolve over time as more informationcomes to hand [Bieling and Kuyken, 2003]. Eells et al.

[1998] assert that CFs from psychodynamic, cognitive,behavioral, and interpersonal therapies have threefeatures in common. Firstly, they make inferencesabout the client’s presenting problem that are sup-ported by the client’s own interactions in treatment.Secondly, the inferences made in the CF process areconcluded on the basis of the treating clinician’s ownknowledge and judgement, rather than the self-reportof the client. Thirdly, CFs are ‘compartmentalized’(p 145) with an overall formulation being produced asthe sum of a collection of smaller components.

A distinction has also been made by previous authorsbetween overall, comprehensive formulations of theentirety of a client’s presenting problem, versus smaller,specific formulations of separate situations [e.g. Persons,1989; Persons and Tompkins, 1997]. Complex casesmay involve multiple different presenting problems,

Published online 26 March 2007 in Wiley InterScience (www.

interscience.wiley.com).

DOI 10.1002/da.20301

Received for publication 14 September 2006; Revised 6 December

2006; Accepted 2 February 2007

�Correspondence to: Dr. Mark J. Boschen, School of Psychology,

Gold Coast campus, Griffith University, PMB50, Gold Coast Mail

Centre, QLD 9726, Australia. E-mail: [email protected]

1Griffith University, Gold Coast, Queensland, Australia2The University of Queensland, Brisbane, Queensland,

Australia

rr 2007 Wiley-Liss, Inc.

with a tangle of interactions that may be difficultto elucidate. Clinicians are often required to chooseor oscillate between specific and monolithicformulations as required to best explain the primarycomplaint.

Despite the importance placed on the developmentof a case formulation in sound clinical practice, manyclinicians may feel under-trained in the area. Thelimited body of research available into clinicians’formulation skills suggests clinicians feel under-trainedin formulation skills, and trainers see the importance ofimproving training in CF [Ben-Aron and McCormick,1980; Fleming and Patterson, 1993]. Despite theapparent desire of clinicians and clinical trainers toincrease the quality of CF skills, there is little publishedresearch into the formulation skills of clinicians,particularly within a cognitive behaviour therapycontext [Eells et al., 1998].

Case formulation is an approach to the developmentof treatment plans that fits well within the scientist-practitioner model that dominates clinical psychologytraining and practice [Baker and Benjamin, 2000].Scientist-practitioners draw on research evidence toinform clinical practice, and evaluate interventionsusing scientifically supported methodologies. The useof a CF approach incorporates not only a descriptiveaccount of the presenting problem, but also thetherapist’s inferences about the underlying processesthat can be tested as hypotheses as an integral part ofthe intervention. Indeed, the ability to approach caseswithin a scientist-practitioner framework requires that asufficiently detailed CF has been generated as a startingpoint for hypothesis generation.

Methods and systems for developing individual caseformulations for use in clinical practice have beendeveloped for many different psychotherapy schools.Cognitive behaviour therapists have developed severalsystematic methods of formulating clinical cases [e.g.Beck, 1995; Mumma, 2004; Persons and Tompkins,1997]. Despite the existence of these formulationsystems, it has been suggested that clinicians in practiceare more likely to use a less systematic method toconceptualise clients’ presenting problems [Bieling andKuyken, 2003]. This is of concern when evidence thatsystematic methods of CF are known to improve inter-clinician reliability [Persons and Bertagnolli, 1999].

WHY USE CASE FORMULATION?

Previous authors have keenly highlighted the pur-ported advantages of using CF in psychotherapy. It hasbeen suggested that the use of a systematic CFapproach gives the clinician a theory-based frameworkfrom which to make inferences about the nature of aclient’s problems. Individual CFs allow the provisionof individual treatment plans, rather than manualisedtreatment delivery. The collaborative process used forCF used in cognitive behaviour therapy may alsoenhance therapist and client understanding of the

presenting problem. When presented collaboratively,such individualised CFs may also strengthen thetherapeutic alliance. Furthermore, by suggesting morespecific, precise interventions, therapeutic outcome canpotentially be enhanced [Bieling and Kuyken, 2003].Such an approach is also suggested to be more usefulthan a diagnosis-based treatment planning approach[e.g. Persons, 1986], and may address concerns aboutthe limits to categorical diagnosis [e.g. Widiger andCoker, 2003].

The overall quality of case formulations has beenassessed in several recent studies by Kuyken et al.[2005] and Eells et al. [2005]. Both these studies founda large variance in case formulation quality. Eells et al.[2005] reported that case formulation quality variedas a function of therapist expertise, but not orientation.Heiner et al. [2006] also reported on the quality of caseformulation in trainee and experienced therapists,again finding a wide range in the quality of formula-tions provided by trainees and practicing clinicians.

Despite the eagerness to advocate for a CF approachto treatment planning, there exists a paucity of researchto support these suggested advantages of CF. There areremarkably few systematic studies of the advantages ofCF, and those that have been conducted offer only verylimited support [Bieling and Kuyken, 2003].

One proposed advantage of systematic CF methodsis that they serve to enhance agreement amongclinicians as to the causal and maintaining factorsrelevant to the client’s presenting problem. This inter-rater reliability of individual CFs is an essential pre-requisite to demonstrating their validity. In cognitivebehaviour therapy, there is preliminary evidence forinter-rater reliability of CFs [Persons et al., 1995;Persons and Bertagnolli, 1999]. Moreover, the relia-bility of cognitive behavioral formulations can befurther enhanced through a systematic approach,whereby a set of specific domains is specified [Personsand Bertagnolli, 1999]. Despite this, there is alsoevidence that the emphasis in cognitive behavioral CFsmay be stronger for the descriptive component of theformulations than the inferential component, and thatinter-rater reliability may also be higher in descriptionthan inference [Eells et al., 1998]. More recently,Kuyken et al. [2005] examined the reliability andquality of case formulation, replicating the finding thatthere is greater inter-rater reliability for descriptivethan inferential formulation elements.

The ability of CF to improve clinical outcomes ishighlighted as the key factor in its utility. Some authorshave opined that the ability of CF to improve clinicaloutcomes is the foremost in determining its value [e.g.Hayes et al., 1987]. Despite the apparent face-validityof such assertions, there remains surprisingly littleevidence supporting the assertion that CF enhancesoutcome in treatment [Bieling and Kuyken, 2003].Using cognitive analytic therapy, Evans and Parry[1996] attempted to evaluate the impact of a colla-borative CF, delivered in the fourth session, on

812 Boschen and Oei

Depression and Anxiety

treatment outcome in a small sample of four patients.In this study, the authors found that the collaborativeCF had little impact on client or therapist perceptionof treatment efficacy. The failure of CF to improvecognitive behaviour therapy outcome was also morerecently supported in a group of psychotic patients[Chadwick et al., 2003]. It should be noted that in bothof these studies, particularly difficult patient groupshad been used, and as such may not accuratelyrepresent the impact of CF on all clinical cases.Psychodynamic researchers have reported that out-come may be enhanced by adherence to a formulation-based treatment plan [Crits-Cristoph et al., 1988],however this is somewhat different to the impact of theCF itself on outcome. It would seem self-evident that aformulation can only be effective if it is actually utilisedin treatment planning and delivery. We would suggestthat adherence to formulation may mediate the impactof the formulation itself on treatment outcome.

There has been limited research comparing clinicaloutcomes from manualised versus formulation-basedtreatment approaches. Earlier research appeared tosuggest that manualised treatment approaches mayoffer superior outcomes, however more recent workhas called these early findings into question. Eells et al.[2005] compared formulation-based treatment ofanxious/depressed outpatients, and reported effect sizesof their treatments that were similar to that publishedpreviously. Similarly, Ghaderi [2006] reported on acomparison between manualised and individualisedtreatment for bulimia nervosa. Despite similar overalleffect-sizes in the two groups, when treatment non-responders were examined, it was found that theoverwhelming majority (80%) of these were from themanualised treatment group. The author used thesefindings to suggest preliminary evidence for theadvantage of individualised, formulation-based treat-ment approaches.

In addition to clinical outcome, the impact of CF onother variables has been examined, again in a smallnumber of studies. Chadwick et al. [2003] reported thateven though CF did not improve clinical outcomes orpatient perceptions of the strength of the therapeuticalliance, it did improve therapist perception of alliancestrength. Other potential advantages to the use of CFhave not been systematically studied. These includeratings of therapist confidence, extent of collaborationin treatment planning, awareness, and consideration ofthe wide range of causal and maintaining factors inpsychopathology, and extent of strategic forward-planned interventions.

CASE FORMULATION IN ANXIETYDISORDERS

Cognitive behaviour therapy has gained prominenceas the psychological treatment of choice for the anxietydisorders [e.g. Andrews et al., 2004; Barlow et al., 2002;Franklin and Foa, 2002; RANZCP Clinical Practice

Guidelines Team for Panic Disorder and Agoraphobia,2003]. Current cognitive behavioral treatments foranxiety disorders draw on empirically based theoreticalmodels to support use of specific treatment techniquesand processes.

There exists some controversy within the anxietydisorder literature as to the taxonomy of anxietyproblems. One body of literature has advocated for acategorical taxonomy in which the anxiety disorders areconsidered qualitatively different in presentation [e.g.APA, 2000; Krueger, 1999]. Despite the empiricallydemonstrated ability of diagnostic interviews to dis-criminate between different anxiety disorder, it is alsorecognised that commonality is readily observed [e.g.Krueger, 1999], leading other researchers to assert thatthe anxiety disorders are more alike than different.Common underlying personality dimensions have alsobeen isolated which provide some level of unificationamong the anxiety disorders [e.g. Andrews et al., 1990].

Despite some obvious surface differences, all of theanxiety disorders share a core set of common symp-toms. All anxiety disorders show varying manifestationsof the subjective, physiological, and behavioral symp-toms of anxiety [Barlow, 1988]. In addition, all anxietydisorders are thought to share distortions in cognitivecontent [Beck, 1976; Beck and Emery, 1985] andprocesses [e.g. Mogg and Bradley, 1998]. Althoughthese basic anxiety symptoms are present in alldisorders, they may manifest differently in each [Beidelet al., 2003]. For example, although both panic disorderand social phobia may exhibit physiological arousalsymptoms, patients with panic are more likely toexhibit paresthesias, lightheadedness, and breathingdifficulty [Page, 1994]. It is suggested here that thecommon elements to the anxiety disorders allow asingle unified framework to be used in CF developmentand treatment planning.

THE COGNITIVE BEHAVIORALCASE FORMULATION

FRAMEWORKThe cognitive behavioral case formulation frame-

work (CBCFF) for anxiety disorders presented hereinaims to enhance clinical practice in a number of ways.Similarly to other CF methods proposed previously, itaims to improve inter-clinician reliability in concep-tualisation by providing a clear structural framework.When used collaboratively in psychoeducation andtreatment negotiation with the client, it is suggestedthat the anxiety disorder CBCFF may serve to enhancethe strength of the therapeutic alliance through itsemphasis on developing a shared understanding of theclient’s presentation. At a more fundamental level, theCBCFF for anxiety disorders aims to assist the clinicianin understanding the interplay of different cognitiveand behavioral mechanisms in anxiety aetiology andmaintenance. A ‘monolithic’ model incorporating a

813Theoretical Review: Case Formulation in Anxiety Disorders


wide range of these mechanisms also encouragesclinicians to consider aetiological and maintainingfactors from an extensive smorgasbord of possiblemechanisms. Furthermore, through encouraging alogical, structured approach to formulation, it en-courages clinicians to operate similarly in their treat-ment planning, constructing a series of interventioncomponents that are supported by aspects of the CF.

The anxiety disorder CBCFF is presented in aflowchart in Figure 1. The use of a flowchart ratherthan other methods to describe the CBCFF has been adeliberate decision, aimed at enhancing its utility.Flowcharts are comparatively easy to read, providingclear indications of progression from one step toanother [Kammann, 1975], especially when presentedin a format that mirrors normal reading [i.e. left-to-right flow; Krohn, 1984]. Flowcharts have beensuggested as an effective aid to training in behaviourtherapy [Craighead et al., 1979], and have beenincorporated into behavioral treatment procedures[e.g. Danforth, 1998].

The use of the CBCFF for anxiety disorders intreatment planning is consistent with the principles ofthe scientist–practitioner model. It guides the cliniciantowards consideration of formulation componentsthat are supported by the cognitive behavioral treat-ment literature. By presenting a large array ofaetiological and maintaining factors, it encouragesthe clinician to look broadly, rather than consideringonly the immediately apparent mechanisms. TheCBCFF also presents obvious hypotheses for testingin the treatment process. Inferences such as the likelyeffect of specific treatment components on specificformulation factors (and psychopathology) are readilyapparent when treatment plans are constructed usingthe model.

The CBCFF for anxiety disorders is also consistentwith the three common features of CFs specified byEells et al. [1998]. Firstly, the CBCFF for anxietydisorders suggests formulation components that can beelucidated from the information gathered from theclient during therapy sessions (and other cognitive/behavioral assessment methods). Secondly, the compo-nents of the anxiety disorder CBCFF are generallyinferred by the clinician, rather than devised exclusivelyfrom client self-report. It is important to acknowledgehere, however, that inferences made by the client as tothe causal and maintaining factors in their presentingproblem may yield important information for theCF. Thirdly, the CBCFF is constructed of componentsthat are built together to construct an overallcomprehensive CF.

It is apparent that the CBCFF for anxiety disordersdoes not incorporate a holistic view of the patient,but is instead focuses on the problems for whichthey are seeking treatment. This is consistent with theideas of previous researchers who have emphasised thatthe CF is a description of the presenting problem,rather than of the whole person [Bieling and Kuyken,2003].

DESCRIPTION OF THE CBCFFFOR ANXIETY DISORDERS

The CBCFF for anxiety disorders is presented as aflowchart in Figure 1. In general terms, the CBCFFdescribes a chain of events, behaviours and cognitions,as well as the interplay and enduring effects of these(e.g. reinforcement of certain behaviours). Broadly, theleft-to-right chain in the CBCFF (shown with a boldarrow running through the centre of the flowchart)describes a situation where an anxious individual comes

Figure 1. A cognitive behavioral case formulation framework (CBCFF) of anxiety disorders and associated treatment components.

814 Boschen and Oei


into contact with a stimulus that is perceived asdangerous, and then acts in such a way to reduce theensuing anxiety. Other cognitive variables such asattentional biases and self-efficacy beliefs are alsoshown to impact on this basic chain. The chain is arecognisable expansion on the basic SORC modellong-used in behaviour therapy formulation [e.g.Kanfer and Saslow, 1969].

Three different symbols are used within the CBCFFflowchart to denote different component types.Thought bubbles and six-sided shapes are used torepresent cognition and behaviour, respectively. Rec-tangular symbols are used to represent other compo-nents such as consequences of behaviour, interoceptivecues, and some stimuli. Arrows are used to show theflow from one component to another.

COMPONENTS OF THE CBCFFFOR ANXIETY DISORDERS

Each of the components of the CBCFF for anxietydisorders is reviewed below. The review is briefand does not attempt to encompass all that is knownabout each specific component, instead presentinga basic description of the component, how it impactson aetiology and maintenance of anxiety disorder,and the interventions that can be directed at eachcomponent.

APPROACH BEHAVIORS

Contact with anxiety eliciting stimuli often occursas the result of the behaviour of the individual. Forexample, a client with agoraphobia becomes anxiousafter the approach behaviour of entering a shoppingcentre. The client’s approach behaviour forms the firstelement in the CBCFF chain, leading the individual tothe anxiety-provoking stimulus. Exposure-based inter-ventions call specifically for an increase in thefrequency of approach behaviour (see Fig. 1 andTable 2).

STIMULUS

The exact nature of the feared stimuli differs amongindividuals, and is focused on different areas indifferent anxiety disorders. Feared stimuli can bedrawn from numerous sources, including externalobjects or situations, interoceptive stimuli, and cogni-tions. Tables 1 and 2 include a list of the specific stimulithat are the foci of different anxiety disorders. Socialphobia, for example, has as its anxiety-provokingstimulus the perception that one is under scrutiny[the perceived ‘audience’, Rapee and Heimberg, 1997,p 744]. In panic disorder, alternatively, the primaryfeared stimuli are interoceptive cues [Barlow, 1988;Clark, 1986]. Figure 1 shows that the stimuli them-selves are not directly targeted by any particularcognitive behavioral intervention.

For the purposes of case formulation andtreatment planning, the identification of the correctstimulus is essential. The anxiety-provoking stimulusis presented during exposure treatments, with theaim of reducing the anxiety it elicits, as well asthe urge to reduce this anxiety. Obviously, exposureusing an incorrect stimulus is likely to be ineffective,at best.

HYPERVIGILANCE TO STIMULUS

Individuals with anxiety disorder often show measur-able tendencies to attend to threatening stimuli. Clientswith obsessive-compulsive disorder, for instance,attend to normal intrusive thoughts [Rachman andde Silva, 1978; Salkovskis, 1999; Salkovskis andHarrison, 1984]. In contrast, patients with panicdisorder may show heightened attention to interocep-tive cues [e.g. Lang and Sarmiento, 2004], while thosewith social phobia are more likely to orient to sociallythreatening stimuli such as critical faces [e.g. Bogelsand Mansell, 2004].

Interventions such as distraction and attentionaltraining are aimed at addressing hypervigilance tothreat stimuli in anxiety. There is evidence thatcorrection of these biases is associated with successful

TABLE 1. Feared stimuli and anxiety reducing behavior in different anxiety disorders

Disorder Stimulus Perception of danger Anxiety reducing behaviour

Panic disorder Interoceptive cues Catastrophic cognitions Safety seeking; avoidanceAgoraphobia Feared location Occurrence of panic symptoms Safety seeking; avoidanceSpecific phobia Phobic stimulus Occurrence of anxiety

symptoms; occurrence ofnegative outcome from stimulus

Safety seeking; avoidance

Social phobia Perceived audience Fear of negative evaluation Safety seeking; avoidanceObsessive-compulsive disorder Obsession Doubt; responsibility CompulsionPosttraumatic stress disorder Trauma related objects,

cognitions, or situationsRe-experiencing or recurrence

of traumaAvoidance

Generalized anxiety disorder Worry Validity, utility, anduncontrollability of worry

Attempts to avoid worryor threat



treatment outcomes [e.g. Hofmann, 2000; Lundh andOst, 2001].

PERCEPTION OF DANGER

In line with cognitive views of anxiety psychopathol-ogy [e.g. Beck and Clark, 1997], the CBCFF adheres tothe view that the perception of threat or danger, ratherthan the feared stimulus itself, elicits anxiety. Differentanxiety disorders are thought to perceive threat fromdifferent quarters, as shown in Table 1. Patients withspecific phobias may have anxious thoughts regardingthe risk associated with the feared stimuli (e.g. risk ofbeing bitten by a dog), or about the aversiveness of theanxiety symptoms that the stimulus may elicit [Thorpeand Salkovskis, 1995]. Alternatively, those with ob-sessive-compulsive disorder, panic disorder and socialphobia may have anxiotypic cognitions related toresponsibility [Salkovskis, 1999], the catastrophicnature of physical symptoms [Clark, 1986], or thelikelihood and severity of negative ‘audience’ evalua-tion [Rapee and Heimberg, 1997], respectively.

Cognitive restructuring is the broad name given to ahost of interventions designed to assist the patient inrational evaluation of their cognitions, and modifica-tion of these cognitions with the aim of reducingemotional distress [Beck, 1995]. In the anxiety dis-orders CBCFF, cognitive restructuring is seen as theprimary vehicle by which perceptions of danger are

addressed. Danger cognitions are, of course, addressedalso through the acquisition of new information andexperiential learning (see below).

NEUROTICISM

There is mounting evidence for the existence of a setof personality characteristics that may predisposeindividuals to excessive levels of anxiety [Bienvenuand Stein, 2003]. Neuroticism is recognised as astable, pervasive personality dimension [e.g. Eysenckand Eysenck, 1985; McCrae and Costa, 1996], reflect-ing an individual’s predisposition to experiencingnegative affective states [Costa and McCrae, 1980].Studies which have examined the role of neuroticismhave ascribed approximately half of the variance inemotional distress symptoms to this personality dimen-sion [e.g. Andrews, 1991; Andrews et al., 1993;Duncan-Jones, 1987]. In the anxiety disorders CBCFF,neuroticism is shown to influence both cognition andanxiety symptoms (see Fig. 1). Previous research hasdemonstrated that negative affectivity (NA, a statemeasure of neuroticism) and cognitions have indepen-dent effects on psychopathology symptoms [Jolly et al.,1994].

Figure 1 shows that no cognitive or behavioralinterventions act to directly target neuroticism.Although scores on measures of the neuroticism traitmay change with successful treatment, these changes

TABLE 2. Formulation-based treatment matching

Treatment component CF component addressed Description

1. Exposure Approach behavior Exposure treatments encourage the client to engage in approachbehavior

Punishment of approach behavior When the anxiety caused by the stimulus reduces throughtreatment, punishment of approach behavior reduces

Information or experience Exposure allows the client to acquire corrective informationthrough experiential learning

Increased anxiety Through repeated exposure, habituation occursReduced self-efficacy Successful coping during exposure enhances self-efficacy

2. Safety response inhibition Anxiety reducing behavior Safety response inhibition requires that the client inhibit their usualanxiety reducing behaviors

Reinforcement of anxiety reducingbehavior

By inhibiting anxiety-reducing behaviors, they are no longerreinforced

Reduced self-efficacy Coping with anxiety without performing anxiety-reducingbehavior enhances self-efficacy

3. Cognitive restructuring Perception of danger Cognitive restructuring can be targeted at anxiotypic cognitionssuch as danger expectancies

Information or experience Cognitive restructuring and psychoeducation provide correctiveinformation regarding the level of threat

Reduced self-efficacy Cognitive restructuring can be directed towards self-efficacy beliefs4. Arousal management Increased anxiety Arousal management skills such as relaxation and breathing control

can give some control over increased anxiety levels5. Attention management Hypervigilance to stimulus Distraction and attention training procedures can be taught to help

manage hypervigilance to threat cues6. Surrender of safety signals Reduced self-efficacy By surrendering safety signals, patients learn adaptive self-efficacy

beliefsSafety signals Relinquishing safety signals forms a core treatment component

816 Boschen and Oei


occur indirectly and slowly, rather than from the direct,specific action of any intervention component.

INFORMATION OR EXPERIENCE

Inadequacies in simple associative models of phobiaacquisition have long been recognised, leading toproposals that there may be several methods by whichstimuli come to be appraised as threatening [e.g.Rachman, 1977]. Included in these, is the developmentof fear through direct experience (e.g. being bitten by adog), observation (e.g. seeing someone bitten by a dog),and verbal acquisition (e.g. hearing about someonebitten by a dog).

The process of exposure, although historicallyconceptualised as occurring through conditioningmechanisms, also provides the client with directexperience (and corrective information) regarding thethreat posed by their feared stimulus. Through theirown experience, the patient learns that the threat posedby the feared stimulus may be less, and their ability tocope with the threat may be greater, than previouslysupposed.

In addition to direct experience, Rachman [1977]discusses observational learning as another method offear aetiology. In treatment, this is recognised with theuse of modelling procedures before and duringexposure. Where the therapist demonstrates approachtowards, and tolerance of, a feared stimulus, thismodelling may serve to assist the patient in makingtheir own approach.

Cognitive behavioral treatments for anxiety disordergenerally commence with a period of ‘psychoeduca-tion’, in which information is provided regarding thenature of anxiety and the patient’s psychopathology.Depending on the nature of the presenting problem,other corrective information may be given regardingthe dangerousness of the feared stimuli (e.g. thenormalcy of interoceptive sensations, the risk ofacquiring a serious illness through touching ‘contami-nated’ surfaces, the frequency of intrusive thoughts inthe general population, etc.). Such information may beprovided directly to the patient, or research in the areamay be negotiated as a homework task external to thetherapy session.

Verbal information is also provided and ‘discovered’through cognitive restructuring. During such restruc-turing, the therapist and patient work collaborativelyto identify, evaluate, and adjust problematic ideas andassumptions that may exacerbate anxiety. Verbalinformation provided during therapy sessions is usuallyfurther consolidated experientially through the use ofhomework tasks such as behavioral experiments.

INCREASED ANXIETY

A common feature of the anxiety disorders isexcessive, unreasonable levels of anxiety symptoms.Such anxiety is experienced through a constellation ofemotional, physiological, cognitive, and behavioral

symptoms [APA, 2000; Barlow, 2000]. It is assumedthat these anxiety symptoms are generally aversivewhen they reach excessive levels, and serve to motivatethe individual to withdraw from that which is perceivedas threatening.

A certain level of anxiety symptoms is generally seenas functional, while excessive or inadequate arousallevels impair performance [Andrews et al., 2004].Although a goal of eliminating anxiety is thereforeunrealistic and undesirable, methods of managinganxiety levels are incorporated into most successfulanxiety disorder treatments. Such methods may includerelaxation training [Jacobson, 1938; Ost, 1987] andbreathing control training. These arousal managementskills aim to improve the individual’s ability (andperceived ability) to manage anxious arousal.

REDUCED SELF-EFFICACY

An important component of anxiety disorders is theclient’s perceptions of their ability to cope with anxietyprovoking stimuli and the symptoms that follow. These‘‘beliefs and attitudes that people hold about theirability to cope, or performya given behaviour’’together comprise an individual’s self-efficacy [John-stone and Page, 2004, p 252]. Self-efficacy beliefs havebeen implicated in panic disorder [e.g. Casey et al.,2004], agoraphobia [e.g. Hoffart, 1995a,b], shyness andsocial phobia [e.g. Caprara et al., 2003], specific phobia[e.g. Jones and Menzies, 2000], and posttraumaticstress disorder [e.g. Benight and Bandura, 2004], aswell as the general concept of anxiety [Bandura, 1983].

Within the anxiety disorder CBCFF presented inFigure 1, reduced self-efficacy is shown to haveinfluence on two other components. Firstly, self-efficacy influences the individual’s perception of dangerwhen the feared stimulus or situation is present.Bandura [1983] has suggested that people’s ‘‘perceivedinefficacy in coping’’ (p 465) is primary in determiningwhether a stimulus or situation elicits anxiety. Patientsbrought into contact with threatening stimuli show agreater perception of danger (and therefore greateranxiety) when they perceive that they are unable tocope with the situation and/or the anxiety it generates.Secondly, self-efficacy is shown in Figure 1 to influencethe ability of anxiety to lead to anxiety-reducingbehaviour. Where an anxious individual perceives thatthey are able to tolerate (or manage) their anxietysymptoms, their perceived need to reduce thesesymptoms through avoidance, checking, or otheranxiolytic behaviour is reduced.

Figure 1 shows that an individual’s self-efficacyperceptions are a direct target of several interventionsoften used in the treatment of anxiety disorders.Having the person refrain from the use of their typicalanxiety-reducing behaviour, as well as surrendering anysafety signals (see below), is suggested to strengthenbeliefs in their ability to tolerate the associated anxiety.Specific self-efficacy beliefs can also be viewed as a



direct target for cognitive restructuring, usually withfollow-up behavioral experiments designed to consoli-date any cognitive change. Furthermore, the teachingof arousal management skills like relaxation andbreathing control may enhance some peoples’ beliefsin their ability to cope in the face of anxiety.

ANXIETY REDUCING BEHAVIOR

It is considered adaptive and functional for anorganism to seek to reduce its overall anxiety level. Awide variety of behaviours are used by people with andwithout clinical anxiety problems to reduce or manageanxiety levels. In anxiety disorders, such behaviours areused either too frequently, or without sufficientflexibility, thereby impairing functioning. The choiceof anxiety-reducing behaviour used by individuals isinfluenced largely by the nature of the anxiety-provoking stimuli. Where the feared stimulus is aspecific object (as in specific phobia), the simplestbehaviour to reduce anxiety is to withdraw from (andsubsequently avoid) the object. Where the fearedsituation is a certain place (as in agoraphobia),avoidance/escape may also be the primary anxiety-reducing behaviour. In disorders such as panic,individuals may behave in such a way as to minimisethe severity of interoceptive cues by avoiding exerciseor other similar activity. Where the feared stimulus isan intrusive thought (as in some cases of OCD andPTSD), the mechanism to reduce anxiety is often oneof ‘cognitive avoidance’ whereby the individual at-tempts to avoid or suppress anxiogenic thoughts orimagery.

In the anxiety disorders CBCFF, anxiety-reducingbehaviour is directly elicited by the experience ofincreased anxiety. Elevated anxiety serves as a dis-criminative stimulus to indicate to the individual thatcertain behaviours will be followed by anxiety reduc-tion. Figure 1 also shows a link between the use ofanxiety reducing behaviour, and perceptions of lowself-efficacy. It is suggested that failure to manageanxiety in a given situation, and the behaviour used toreduce this anxiety, strengthen beliefs about theindividual’s poor ability to cope.

As part of treatment of anxiety disorders, anindividual needs to refrain from the behaviours theyusually use to relieve anxiety. When these anxiety-reducing responses are inhibited, the usual pattern ofnegative reinforcement is circumvented. Furthermore,the individual’s perception of their coping ability isstrengthened. Such inhibition is labelled as ‘safetyresponse inhibition’ in Figure 1. This concept incor-porates the ‘response prevention’ treatment componentused in OCD but it should be recognised that thisprinciple to all anxiety conditions. Any exposure wherepatients are asked to refrain from their usual safetybehaviours (e.g. escape) is conceptualised in theCBCFF as a form of ‘safety response inhibition.’

SAFETY SIGNALS

Many anxiety-reducing behaviours are aimed atattaining a sense of safety through the generation ofsafety signals [Gray, 1975; Rachman, 1984]. A distinc-tion is made in the CBCFF for anxiety disordersbetween anxiety-reducing behaviours and safety sig-nals. While anxiety reducing behaviours are operantswhich are open to reinforcement, safety signals arestimuli which indicate that an aversive outcome is lesslikely. For example, taking a diazepam tablet may be abehaviour which is reinforced through its ability toreduce anxiety. On the other hand, carrying the sametablet in a purse is a behaviour aimed at perpetuatingthe safety signal of the tablet’s presence—a stimuluswhich has become associated with reduced anxiety.Other examples of safety signals may be the presence ofa relative (or the therapist), knowledge of the locationof the nearest toilet, or familiar, comfortable surround-ings.

In the CBCFF for anxiety disorders (Fig. 1), safetysignals relate to three other components. Firstly, theyshow a reciprocal relationship with reduced self-efficacy. It is suggested that the use of safety signalsoccurs, at least in part, due to a person’s perceivedinability to cope with anxiety in the absence of thesafety signal. Conversely the ongoing use of suchsignals further erodes the person’s perception of theirinherent coping skill. Over time, safety signals may alsobecome associated with reduced anxiety, throughclassical conditioning mechanisms.

Safety signals may play a role in successful treatmentof anxiety [e.g. Sartory et al., 1989]. A significantcomponent of treatment during exposure is thesurrendering of previously used safety signals. As theindividual learns through experience that their anxietycan be managed without the use of their previous safetysignals, their self-efficacy is enhanced. Throughexposure and increasing self-efficacy, the perceivedneed to use safety signals further decreases.

REDUCED ANXIETY ANDREINFORCEMENT OF ANXIETYREDUCING BEHAVIORS

Anxiety reducing behaviour, and the presence ofsafety signals, lead to a drop in overall anxious arousalsymptoms. The reduction in anxiety symptoms thatoccurs following anxiety-reducing behaviour serves toreinforce the use of such operants, making their futureuse more likely. In anxiety disorders, commonlyobserved patterns of avoidance are explained throughthis cycle. The CBCFF for anxiety disorders clearlyshows, in a visual format, the negative reinforcementcontingency operating on the anxiety-reducing behaviour.

During anxiety disorder treatment, the individualinhibits their normal anxiety-reducing behaviour, thuspreventing it being further reinforced. Over time, asthe behaviour is not reinforced, it is subject toextinction.

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PUNISHMENT OF APPROACH BEHAVIORS

The increase in arousal symptoms that accompaniesthe perception of danger is generally an aversive,punishing experience. When such anxiety occursfollowing an individual’s approach behaviours, thiscondition acts as a positive punisher on these operants,reducing their likelihood in future.

Exposure is shown in the CBCFF as the cognitivebehavioral treatment component directed at thepunishment of approach behaviours. It is hypothesisedthat habituation occurs over repeated exposure to thefeared stimulus, and that the punishing effects ofanxiety are diminished.

FORMULATION-BASEDTREATMENT MATCHING

An example is provided to illustrate the potentialuses for the CBCFF for anxiety disorders. The exampleuses the CBCFF to formulate a single individualclinical case, and then to derive a novel formulation-based treatment plan.

CLINICAL CASE EXAMPLE

Figure 2 presents the use of the CBCFF in the caseformulation of an individual with emetophobia (fear ofvomiting) who presented for treatment with the firstauthor. LJ, a 30 year old married woman, presented toa university psychology clinic complaining of persis-tent, debilitating concerns that she would becomenauseous or vomit. LJ reported avoidance of numerous‘risky’ foods such as seafood and poultry. At varioustimes, when either exposed to risky stimuli, or when LJexperienced normal gastrointestinal (GI) cues (such asthose experienced with hunger and normal digestiveprocesses) she would begin to focus on automaticthoughts that she would imminently become severely

nauseous and vomit. Through ongoing concern, LJhad also become hypervigilant to such GI cues. Whenshe perceived that nausea/vomiting was likely, this ledto an understandable increase in anxiety, and anaccompanying withdrawal from activity. Furthermore,LJ would repeatedly seek reassurance from her hus-band that she was not looking pale or sickly. Suchreassurance was negatively reinforcing, providingtemporary anxiolysis. LJ’s husband had been elistedinto the role of a safety signal also, with his presencehelping to reduce anxiety. LJ’s repeated need forreassurance, and recurrent attacks of nausea had also,by the time of presentation, led to a severe reduction inLJ’s self-efficacy perceptions about her ability tomanage illness or nausea.

Figure 3 illustrates how each of the formulationcomponents suggests items for a treatment plan. Thecomponents of a treatment plan, along with theformulation factors from which they are derived, arepresented in Table 3. It is worth noting that thetreatment plan derived here is similar to that suggestedpreviously for treatment of emetophobia [Boschen,in press].

DISCUSSIONThe CBCFF for anxiety disorders has been gener-

ated with the aim of presenting a single, visual model ofanxiety disorders, from which formulation-based treat-ment plans can be derived. The model presented hereachieves this goal, although further empirical testing ofthe impact of the CBCFF for anxiety disorders isrequired.

LIMITATIONS OF THE CBCFFFOR ANXIETY DISORDERS

It could be argued that the CBCFF presented here isalso limited in that it does not clearly recognise the

Figure 2. Individual case formulation example.



differences of formulation and treatment betweendifferent anxiety disorders. We believe, however, thatthe flexibility inherent in the CBCFF allows forformulation of different anxiety disorders within thesame overarching conceptual framework. While suchan approach may simplify our current understanding, itis argued here that such simplification may make

clinical formulation and treatment planning an easierundertaking, without sacrificing treatment outcome.

The CBCFF for anxiety disorders artificially ex-cludes the impact of other comorbid personalityvariables and psychopathological processes on anxietydisorders. For example, the complex interactionbetween anxiety disorders and commonly comorbid

TABLE 3. Case example formulation-based treatment matching

Treatment component CF component addressed Description

1. Exposure Avoidance of risky foods, etc. Exposure treatments encourage the client to expose themselvesto stimuli perceived as risky

Punishment for contact with riskystimuli

When the anxiety caused by risky foods, people, and situations reducesthrough treatment, punishment of approach behavior reduces

Increased anxiety Through repeated exposure to risky stimuli, habituation occursPerceived inability to inhibit

reassurance seekingSuccessfully exposing to risky stimuli, without withdrawal or

reassurance enhances self-efficacy2. Safety response inhibition Reassurance seeking behavior Safety response inhibition requires that the client refrain from seeking

reassurance from her husbandReinforcement of reassurance-

seekingBy inhibiting the reassurance-seeking, it is no longer reinforced

Perceived inability to cope withouthusband

Coping with anxiety/nausea without husband enhances self-efficacy

3. Cognitive restructuring Catastrophic belief that nausea orvomiting is imminent

Cognitive restructuring can be targeted at cognitions about thelikelihood and implications of nausea or vomiting

Perceived inability to inhibitreassurance seeking

Cognitive restructuring can be directed towards beliefs about theclient’s ability to resist the urge to seek reassurance

4. Arousal management Increased anxiety Arousal management skills such as relaxation and breathing controlmay help control arousal and associated nausea levels

5. Distraction/attention skills Hypervigilance to gastrointestinalcues

Through learning that the occurrence of GI cues is not dangerousand does not lead to vomiting, the need to remain hypervigilantto them is reduced

6. Surrender of safety signals Reduced self-efficacy By increasing activities without the husband, LJ learns adaptiveself-efficacy beliefs

Safety signals Relinquishing safety signals forms a core treatment component

Figure 3. Individual formulation-based treatment planning example.

820 Boschen and Oei


mood problems is not considered. This is seen as areflection of the scope of the model, rather than afailing of the CBCFF concept. Competent cliniciansusing the CBCFF for anxiety disorders should remainmindful of comorbid diagnoses, as well as other factorsnot specified within the model which may also havebearing on the client’s presenting problem.

The ‘perception of danger’ component of theCBCFF for anxiety disorders is acknowledged as asimplistic representation of the role of cognition in theaetiology and maintenance of anxiety disorder. It doesnot differentiate between different levels of cognitionsuch as automatic thoughts, intermediate beliefs, andschemas [Beck, 1995]. Nor does it adequately addressthe difference between cognitive content and cognitiveprocesses that operate in anxiety disorders. Like manyaspects of the CBCFF for anxiety disorders, it ispresented as a simplification to assist in conceptualisingand planning treatment, rather than a comprehensiveexplanation. Other important components known to berelevant to anxiety disorders such as the impact ofsocial and systemic factors [e.g. Tarrier and Callum,2002] are also not fully incorporated, and should beconsidered by clinicians using the CBCFF.

The last few years have seen the expansion of modelsof anxiety disorder to incorporate new concepts such asmindfulness and metacognition [e.g. Miller et al., 1995;Wells, 2000; Wells and Carter, 2001]. The currentCBCFF does not incorporate these components,although their integration into the overall model isunlikely to be difficult. As further evidence clarifies theexact nature of these and other constructs, it isrecommended that they be incorporated into formula-tion systems such as the CBCFF.

CONCLUSIONS

The cognitive behavioral case formulation frame-work (CBCFF) for anxiety disorders is a singlecognitive-behavioral framework for understandingand treating anxiety disorders using formulation-basedtreatment plans. It encourages clear understanding ofthe cognitive and behavioral factors which cause andmaintain anxiety disorder symptoms, as clear andspecific links between these factors and treatmentcomponents. There is a clear need to evaluate thepurported advantages of such a system empirically.

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