Case Conceptualization PDF

Case Conceptualization Client Information:  Name: Sarah  Age: 25 years  Gender: Female  Presenting Issue: Anxiety and difficulty with emotional regulation Presenting Problem: Sarah, a 25-year-old female, sought therapy due to increasing anxiety and emotional regulation di...

Case Conceptualization Client Information:  Name: Sarah  Age: 25 years  Gender: Female  Presenting Issue: Anxiety and difficulty with emotional regulation Presenting Problem: Sarah, a 25-year-old female, sought therapy due to increasing anxiety and emotional regulation difficulties. She described feeling constantly on edge, struggling to manage stress, and frequently becoming overwhelmed by small tasks. Sarah reported experiencing panic attacks at least twice a week, particularly when facing deadlines or high expectations at work. She expressed concerns about being unable to balance her professional life with her personal relationships, often avoiding social interactions due to fear of being judged. Background Information: Sarah has a history of generalized anxiety, dating back to her teenage years. She described her parents as supportive, but she felt pressure to excel academically from a young age. Sarah mentioned that her parents, particularly her mother, had high expectations, which she internalized. Throughout high school and university, she coped by overachieving, but this pattern has led to burnout in recent years. She works as a marketing manager, where she feels immense pressure to meet deadlines and perform at a high level. Her work environment is competitive, and she has difficulty asserting herself or asking for help. Sarah avoids confrontation and fears being perceived as incompetent. Socially, Sarah has a close circle of friends but often feels detached. She reported struggling to maintain relationships, especially during periods of high anxiety. She also mentioned that her romantic relationships often end due to her emotional unavailability and fear of rejection. Assessment Results:  GAD-7 (Generalized Anxiety Disorder scale): Moderate to severe anxiety (score: 16/21).  Beck Depression Inventory (BDI-II): Mild depressive symptoms (score: 10/63).  Difficulties in Emotion Regulation Scale (DERS): Elevated scores in emotional awareness and impulse control subscales, indicating difficulty in recognizing emotions and regulating reactions. Theoretical Orientation and Case Conceptualization: Using Cognitive Behavioral Therapy (CBT) as the primary framework, Sarah’s anxiety is conceptualized as stemming from maladaptive thought patterns that have developed due to early experiences of high expectations. Her perfectionism, rooted in fears of failure, leads her to interpret stressful situations as catastrophic, causing heightened anxiety. Her core beliefs include "I am not good enough" and "I must always be perfect to be accepted." These beliefs lead to automatic thoughts such as "If I make a mistake, I will be rejected," which then trigger physiological responses like panic attacks and emotional dysregulation. Behaviorally, Sarah copes by avoiding conflict and overworking, leading to increased stress and isolation. Her emotional regulation difficulties, as indicated by her DERS results, exacerbate her anxiety, creating a cycle of emotional overwhelm followed by withdrawal. Case Formulation:  Precipitating Factors: Work stress, personal expectations, and lack of assertiveness in professional and personal settings.  Predisposing Factors: Childhood experiences of pressure to achieve, perfectionism, and fear of judgment.  Perpetuating Factors: Avoidant behavior, negative thought patterns, and emotional regulation issues.  Protective Factors: Close friendships, supportive family, and a willingness to seek help. Treatment Plan: 1. Cognitive Restructuring: Challenge Sarah’s perfectionistic beliefs and catastrophic thinking through cognitive restructuring. Help her recognize and reframe maladaptive thought patterns that contribute to her anxiety. 2. Emotion Regulation Skills: Introduce Dialectical Behavior Therapy (DBT)- informed techniques, such as mindfulness and distress tolerance, to help Sarah become more aware of her emotions and manage overwhelming feelings in a healthy way. 3. Exposure to Anxiety Triggers: Gradual exposure to situations that trigger Sarah’s anxiety (e.g., social situations, work presentations) to reduce avoidance and build resilience. 4. Assertiveness Training: Work on developing assertiveness skills to help Sarah communicate her needs at work and in relationships without fear of judgment. 5. Stress Management: Introduce relaxation techniques such as progressive muscle relaxation and breathing exercises to manage panic symptoms. Prognosis: Given Sarah’s insight into her difficulties and her motivation to engage in therapy, the prognosis is positive. She is likely to benefit from CBT techniques aimed at modifying her thought patterns and DBT skills to manage emotional dysregulation. However, addressing deeply ingrained perfectionistic beliefs will require sustained effort.