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Case Formulation and Disorder-Specific Models

“[Formulation is] The lynch pin that holds theory and practice together” (Butler, 1998).
Cognitive behavioral therapists use individually tailored formulations as a framework with which to understand their patients’ difficulties and to plan effective treatment. A case formulation helps therapists and patients to understand the origin, current status, and maintenance of a problem. Formulations are developed collaboratively between therapists and patients during the assessment phase of therapy and are revised as new information is gathered during the course of treatment. Jacqueline Persons wrote an influential account of individualized case formulation (1989). Her current case formulation approach (2008) describes how a complete CBT case formulation ties together all of the following parts:
  • all of a patient’s symptoms, disorders, and problems;
  • hypotheses about the mechanisms causing the disorders and the problems;
  • proposes the recent precipitants of the current problems and disorders;
  • describes the origins of the mechanisms.
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Problem

Therapy tool

Language

Alternative Action Formulation

The Alternative Action Formulation is a CBT case conceptualization (formulation) worksheet. Formulations help a client and therapist come to a shared ... https://www.psychologytools.com/resource/alternative-action-formulation/

Worksheet

Belief Driven Formulation

Cognitive behavioral theory proposes that our thoughts, feelings, and behavior in the here-and-now are influenced by our schemas / core beliefs / assu ... https://www.psychologytools.com/resource/belief-driven-formulation/

Worksheet

Checking Certainty And Doubt

Psychologists have discovered interesting relationships between Checking, Certainty, And Doubt. This information handout contains an exercise helpful ... https://www.psychologytools.com/resource/checking-certainty-and-doubt/

Exercise

Classical Conditioning

Classical conditioning is a process by which stimuli become associated with responses. This information handout describes key principles of Classical ... https://www.psychologytools.com/resource/classical-conditioning/

Information Handout

Cognitive Behavioral Model Of Anorexia Nervosa (2003)

Anorexia nervosa is an eating disorder characterized by restriction of energy intake and intense fear of gaining weight. For women, the lifetime preva ... https://www.psychologytools.com/resource/cognitive-behavioral-model-of-anorexia-nervosa-2003/

Information Handout

Cognitive Behavioral Model Of Body Dysmorphic Disorder (BDD) (2004)

Individuals with body dysmorphic disorder (BDD) experience distress associated with their body image. The Cognitive Behavioral Model Of Body Dysmorphi ... https://www.psychologytools.com/resource/cognitive-behavioral-model-of-body-dysmorphic-disorder-bdd-2004/

Information Handout

Cognitive Behavioral Model Of Bulimia Nervosa (2003)

Bulimia nervosa is an eating disorder characterized by binge eating followed by purging. Among young women, the point prevalence of bulimia is about 1 ... https://www.psychologytools.com/resource/cognitive-behavioral-model-of-bulimia-nervosa-2003/

Information Handout

Cognitive Behavioral Model Of Fear Of Bodily Sensations (2018)

Fear of bodily sensations is present in a number of conditions, most notably panic disorder. The Cognitive Behavioral Model Of Fear Of Bodily Sensatio ... https://www.psychologytools.com/resource/cognitive-behavioral-model-of-fear-of-bodily-sensations-2018/

Information Handout

Cognitive Behavioral Model Of Generalized Anxiety Disorder (GAD) (1998)

Individuals with generalized anxiety disorder report clinically significant worry alongside physical arousal. The Cognitive Behavioral Model Of Genera ... https://www.psychologytools.com/resource/cognitive-behavioral-model-of-generalized-anxiety-disorder-gad-1998/

Information Handout

Cognitive Behavioral Model Of Health Anxiety (2003)

Individuals with health anxiety experience clinically significant distress associated with health concerns. The Cognitive Behavioral Model Of Health A ... https://www.psychologytools.com/resource/cognitive-behavioral-model-of-health-anxiety-2003/

Information Handout

Cognitive Behavioral Model Of Health Anxiety (2018)

The Cognitive Behavioral Model Of Health Anxiety describes maintaining factors which prolong distress in health-anxious clients. The formulation is pr ... https://www.psychologytools.com/resource/cognitive-behavioral-model-of-health-anxiety-2018/

Information Handout

Cognitive Behavioral Model Of Obsessive Compulsive Disorder (1998)

The essential insight of the cognitive behavioral model of obsessive compulsive disorder (OCD) is that it is the client’s interpretation of the intr ... https://www.psychologytools.com/resource/cognitive-behavioral-model-of-obsessive-compulsive-disorder-1998/

Worksheet

Cognitive Behavioral Model Of Panic (1986)

The Cognitive Behavioral Model Of Panic identifies catastrophic misinterpretation of body sensations as a criticial maintenance factor which serves to ... https://www.psychologytools.com/resource/cognitive-behavioral-model-of-panic-1986/

Information Handout

Cognitive Behavioral Model Of Persistent Postural-Perceptual Dizziness (PPPD) (2017)

Persistent postural-perceptual dizziness (PPPD) is a form of dizziness which is thought to be maintained by psychological factors. ... https://www.psychologytools.com/resource/cognitive-behavioral-model-of-persistent-postural-perceptual-dizziness-pppd-2017/

Information Handout

Cognitive Behavioral Model Of Post Traumatic Stress Disorder (PTSD) (2000)

The Cognitive Behavioral Model Of Post-Traumatic Stress Disorder (PTSD) identifies alterations in memory, cognitions, and behavior as critical mainten ... https://www.psychologytools.com/resource/cognitive-behavioral-model-of-post-traumatic-stress-disorder-ptsd-2000/

Information Handout

Cognitive Behavioral Model Of The Relapse Process (1999)

Marlatt’s (1985) cognitive behavioral model of relapse conceptualizes relapse as a “transitional process, a series of events that unfold over ... https://www.psychologytools.com/resource/cognitive-behavioral-model-of-the-relapse-process-1999/

Information Handout

Cognitive Behavioral Model Of Tinnitus (2014)

The Cognitive Behavioral Model Of Tinnitus identifies cognitive, behavioral, and perceptual changes which operate to maintain tinnitus perception and ... https://www.psychologytools.com/resource/cognitive-behavioral-model-of-tinnitus-2014/

Information Handout

Cognitive Case Formulation

A CBT case conceptualization tool to help therapists derive core beliefs from an analysis of current events. ... https://www.psychologytools.com/resource/cognitive-case-formulation/

Worksheet

Cross Sectional Formulation

Case conceptualizations (formulations) help therapists and clients come to a shared understanding of a problem. This Cross Sectional Formulation explo ... https://www.psychologytools.com/resource/cross-sectional-formulation/

Worksheet

Daily Monitoring Form

Activity diaries can be used for activity monitoring during an assessment phase of therapy, symptom monitoring during therapy, correlating activity wi ... https://www.psychologytools.com/resource/daily-monitoring-form/

Worksheet

Developing Psychological Flexibility

Developing Psychological Flexibility is a client information handout which can be used to familiarize clients with the ACT model. ... https://www.psychologytools.com/resource/developing-psychological-flexibility/

Information Handout

Emotion Focused Formulation

The Emotion Focused Formulation was developed by Isabel Clarke in an acute mental health context but this approach also has wider applicability. It pl ... https://www.psychologytools.com/resource/emotion-focused-formulation/

Worksheet

Emotions Motivate Actions

Many clients find it helpful to recognize the range of actions that are motivated by different emotional states. This worksheet encourages clients to ... https://www.psychologytools.com/resource/emotions-motivate-actions/

Information Handout

Exploring Problems Using A Cross Sectional Model

A cross-sectional formulation takes a ‘snapshot’ of what is going on during a single moment in time. The Exploring Problems Using A Cross-Sectiona ... https://www.psychologytools.com/resource/exploring-problems-using-a-cross-sectional-model/

Worksheet

Exploring Problems Using An A-B-C Model

An Antecedent-Behavior-Consequence (ABC) diagram is a form of functional analysis and is a helpful way of conceptualizing a behavior of interest. It e ... https://www.psychologytools.com/resource/exploring-problems-using-an-a-b-c-model/

Worksheet

Friendly Formulation

Case conceptualizations (formulations) help therapists and clients come to a shared understanding of a problem. This simple CBT formulation worksheet ... https://www.psychologytools.com/resource/friendly-formulation/

Worksheet

Functional Analysis

Functional analysis examines the causes and consequences of behavior. This classic A-B-C Functional Analysis worksheet can be used to collect informat ... https://www.psychologytools.com/resource/functional-analysis/

Worksheet

Functional Analysis With Intervention Planning

This classic A-B-C functional analysis worksheet can be used to collect information about what came before a behavior (antecedents), the behavior itse ... https://www.psychologytools.com/resource/functional-analysis-with-intervention-planning/

Worksheet

How Does Emotion Affect Your Life?

By encouraging your clients to reflect upon the role of emotions in their life you can help them to discuss current difficulties. ... https://www.psychologytools.com/resource/how-does-emotion-affect-your-life/

Exercise

How Does This All Add Up To A Panic Attack? (Psychology Tools For Overcoming Panic)

Psychology Tools for Overcoming Panic takes a cognitive behavioral therapy (CBT) approach to this common anxiety problem. This chapter discusses the ... https://www.psychologytools.com/resource/how-does-this-all-add-up-to-a-panic-attack-psychology-tools-for-overcoming-panic/

Chapter

Longitudinal Formulation 1

Case conceptualizations (formulations) help therapists and clients come to a shared understanding of a problem. This case formulation worksheet is a t ... https://www.psychologytools.com/resource/longitudinal-formulation-1/

Worksheet

Longitudinal Formulation 2

Case conceptualizations (formulations) help therapists and clients come to a shared understanding of a problem. This longitudinal case formulation wor ... https://www.psychologytools.com/resource/longitudinal-formulation-2/

Worksheet

Maintenance Of Obsessive Compulsive Disorder (OCD)

An important treatment implication of the cognitive behavioral model of OCD is that clinicians can work at the level of the meaning of the intrusion. ... https://www.psychologytools.com/resource/maintenance-of-obsessive-compulsive-disorder-ocd/

Worksheet

Making Sense Of Your Panic (Psychology Tools For Overcoming Panic)

Psychology Tools for Overcoming Panic takes a cognitive behavioral therapy (CBT) approach to this common anxiety problem. This chapter brings togethe ... https://www.psychologytools.com/resource/making-sense-of-your-panic-psychology-tools-for-overcoming-panic/

Chapter

Motivation and Ambivalence

Motivation is a necessary precursor to change, yet many clients are ambivalent about the process of change. The Motivation And Ambivalence worksheets ... https://www.psychologytools.com/resource/motivation-and-ambivalence/

Exercise

Motivational Systems (Emotional Regulation Systems)

At the heart of Compassion Focused Therapy (CFT) is an evolutionary model of human motivational systems. Developed by Paul Gilbert it is a helpful len ... https://www.psychologytools.com/resource/motivational-systems-emotional-regulation-systems/

Information Handout

Operant Conditioning

Operant conitioning / instrumental learning is a mechanism by which behaviors can be strengthened or weakened over time. This information handout desc ... https://www.psychologytools.com/resource/operant-conditioning/

Information Handout

Overview Of CBT

Cognitive behavioral therapy (CBT) is an effective treatment for a wide variety of mental and physical health conditions. This information handout des ... https://www.psychologytools.com/resource/overview-of-cbt/

Information Handout

Play The Script Till The End

Fears and worries can operate at different levels. Underlying one fear (e.g. “he won’t turn up”) can be deeper fears (e.g. “no ... https://www.psychologytools.com/resource/play-the-script-till-the-end/

Exercise

Problem List

An important task during the assessment phase of therapy is to identify client difficulties. The Problem List worksheet is a helpful way of gatherin ... https://www.psychologytools.com/resource/problem-list/

Exercise

Process Focused Case Formulation

The Process-Focused Case Formulation encourages clinicians to make hypotheses regarding mechanisms or processes which they believe may be maintainin ... https://www.psychologytools.com/resource/process-focused-case-formulation/

Worksheet

Putting It All Together (Psychology Tools For Living Well)

Cognitive behavioral therapy can help your clients to live happier and more fulfilling lives. Psychology Tools for Living Well is a self-help course ... https://www.psychologytools.com/resource/putting-it-all-together-psychology-tools-for-living-well/

Chapter

REBT Problem Formulation

In Rational Emotive Behaviour Therapy (REBT) emotional problems are dealt with before any others. The REBT Problem Formulation is designed to help cli ... https://www.psychologytools.com/resource/rebt-problem-formulation/

Exercise

Recognizing A Hypomanic Episode

A hypomanic episode is characterized by a period of elevated, irritable, or expansive mood that is abnormal for the individual. The DSM-5 also require ... https://www.psychologytools.com/resource/recognizing-a-hypomanic-episode/

Information Handout

Recognizing A Manic Episode

A manic episode is characterized by a period of elevated, irritable, or expansive mood that is abnormal for the individual.The DSM-5 also requires tha ... https://www.psychologytools.com/resource/recognizing-a-manic-episode/

Information Handout

Recognizing Agoraphobia

Agoraphobia is characterized by a marked fear of situations such as open spaces or public places. Recognizing Agoraphobia compares the DSM-5 and ICD- ... https://www.psychologytools.com/resource/recognizing-agoraphobia/

Information Handout

Recognizing Anorexia Nervosa

Anorexia nervosa is characterized the restriction of energy intake, leading to a severely low weight in the context of an individual’s age, sex, and ... https://www.psychologytools.com/resource/recognizing-anorexia-nervosa/

Information Handout

Recognizing Attention Deficit Hyperactivity Disorder (ADHD)

Attention deficit hyperactivity disorder (ADHD) is characterized by a persistent pattern of inattention and hyperactivity-impulsivity. The ICD-10 clas ... https://www.psychologytools.com/resource/recognizing-attention-deficit-hyperactivity-disorder-adhd/

Information Handout

Recognizing Bipolar Disorder

Bipolar disorder is characterized by distinct episodes of mania or hypomania, and episodes of depression. Recognizing Bipolar Disorder compares the D ... https://www.psychologytools.com/resource/recognizing-bipolar-disorder/

Information Handout

Recognizing Bulimia Nervosa

Bulimia nervosa is characterized by recurrent episodes of binge eating and compensatory behaviors to prevent weight gain. Recognizing Bulimia Nervosa ... https://www.psychologytools.com/resource/recognizing-bulimia-nervosa/

Information Handout

Recognizing Depression

Depression is characterized by an extended period of low mood, anhedonia, and reduction in activity. Recognizing Depression compares the DSM-5 and IC ... https://www.psychologytools.com/resource/recognizing-depression/

Information Handout

Recognizing Generalized Anxiety Disorder (GAD)

Generalized Anxiety Disorder (GAD) is characterized by an extended period of excessive worry. The DSM also emphasizes the importance of the client’s ... https://www.psychologytools.com/resource/recognizing-generalized-anxiety-disorder-gad/

Information Handout

Recognizing Insomnia

Insomnia is characterized by difficulty with sleep quality or quantity. Recognizing Insomnia compares the DSM-5 and ICD- 10 criteria for insomnia and ... https://www.psychologytools.com/resource/recognizing-insomnia/

Information Handout

Recognizing Obsessive Compulsive Disorder (OCD)

Obsessive compulsive disorder (OCD) is characterized by obsessions (cognitive intrusions in the form of thoughts, urges, images, or impulses) and comp ... https://www.psychologytools.com/resource/recognizing-obsessive-compulsive-disorder-ocd/

Information Handout

Recognizing Panic Attacks And Panic Disorder

Panic attacks are characterized by sudden surges of intense fear or discomfort, and panic disorder is characterized by recurrent panic attacks. Recogn ... https://www.psychologytools.com/resource/recognizing-panic-attacks-and-panic-disorder/

Information Handout

Recognizing Persistent Depressive Disorder (Dysthymia)

Dysthymia is characterized by a depressed mood that occurs for most of the day, more days than not, and has been present for at least two years. It is ... https://www.psychologytools.com/resource/recognizing-persistent-depressive-disorder-dysthymia/

Information Handout

Recognizing Post Traumatic Stress Disorder (PTSD)

Post-Traumatic Stress Disorder (PTSD) follows an experience of trauma and is characterized by recurrent involuntary memories or other re-experiencing ... https://www.psychologytools.com/resource/recognizing-post-traumatic-stress-disorder-ptsd/

Information Handout

Recognizing Social Anxiety Disorder

Social Anxiety Disorder is characterized by fear regarding social situations and individuals with social anxiety are concerned about negative evaluati ... https://www.psychologytools.com/resource/recognizing-social-anxiety-disorder/

Information Handout

Recognizing Specific Phobia

Specific phobia is characterized by marked fear or anxiety regarding a particular object or situation. Recognizing Specific Phobia compares the DSM-5 ... https://www.psychologytools.com/resource/recognizing-specific-phobia/

Information Handout

Schema Formulation

Beck’s cognitive model proposes that cognition and perception in the here-and-now is influenced by our ‘schemas’ which shape our per ... https://www.psychologytools.com/resource/schema-formulation/

Worksheet

Stages Of Change

The Stages Of Change model is helpful for conceptualizing the mental states of individuals at different stages of their change journey. This informati ... https://www.psychologytools.com/resource/stages-of-change/

Information Handout

Stages Of Social Anxiety

Stages of Social Anxiety is a CBT worksheet to explore maintaining factors with a client and then to explore possible treatment strategies. ... https://www.psychologytools.com/resource/stages-of-social-anxiety/

Worksheet

SWOT Analysis

SWOT Analysis is a tool, originally from management theory, which can help to guide action in the face of uncertainty or ambivalence. Clients can be a ... https://www.psychologytools.com/resource/swot-analysis/

Exercise

TEAR Model of Grief

Worden formulated the process of grief as consisting of tasks, including accepting the reality of the loss and experiencing its pain. This client info ... https://www.psychologytools.com/resource/tear-model-of-grief/

Information Handout

The Parts Of Your Panic (Psychology Tools For Overcoming Panic)

Psychology Tools for Overcoming Panic takes a cognitive behavioral therapy (CBT) approach to this common anxiety problem. This chapter helps a client ... https://www.psychologytools.com/resource/the-parts-of-your-panic-psychology-tools-for-overcoming-panic/

Chapter

Theory A Theory B

“The most effective way of changing a misinterpretation … is to help the person come up with an alternative, less threatening interpretation o ... https://www.psychologytools.com/resource/theorya-theoryb/

Exercise

Therapy Blueprint

Since the publication of this version of the therapy blueprint we have also developed a more sophisticated version: Therapy Blueprint (Universal) A th ... https://www.psychologytools.com/resource/therapy-blueprint/

Exercise

Therapy Blueprint (Universal)

A therapy blueprint is CBT tool which summarizes the work a therapist and patient have completed together. It represents the past (the problems, what ... https://www.psychologytools.com/resource/therapy-blueprint-universal/

Worksheet

Therapy Blueprint For OCD

A therapy blueprint represents the past (the problems, what maintained them), the present (the therapy itself, new knowledge learned and skills develo ... https://www.psychologytools.com/resource/therapy-blueprint-for-ocd/

Worksheet

Therapy Blueprint For Panic

A therapy blueprint represents the past (the problems, what maintained them), the present (the therapy itself, new knowledge learned and skills develo ... https://www.psychologytools.com/resource/therapy-blueprint-for-panic/

Worksheet

Therapy Blueprint For PTSD

A therapy blueprint represents the past (the problems, what maintained them), the present (the therapy itself, new knowledge learned and skills develo ... https://www.psychologytools.com/resource/therapy-blueprint-for-ptsd/

Worksheet

Thought Challenging Record 7 Column

The thought record is an essential tool in cognitive behavioral therapy (CBT). Thought challenging records help people to evaluate their negative auto ... https://www.psychologytools.com/resource/thought-challenging-record-7-column/

Worksheet

Transdiagnostic Cognitive Behavioral Model Of Eating Disorders (2003)

Fairburn, Cooper & Shafran (2003) argue that eating disorders such as anorexia and bulimia share common maintenance mechanisms despite difference ... https://www.psychologytools.com/resource/transdiagnostic-cognitive-behavioral-model-of-eating-disorders-2003/

Information Handout

TRAP TRAC

TRAP & TRAC worksheets can be usefully used as part of a behavioral activation programme as a way of overcoming responses which result in avoidanc ... https://www.psychologytools.com/resource/trap-trac/

Exercise

Treatment Planning Checklist

Some clients find it difficult to generate treatment goals for therapy. This simple handout presents problems that some people bring to therapy. It ca ... https://www.psychologytools.com/resource/treatment-planning-checklist/

Exercise

Understanding My Panic

The Cognitive Behavioral Model Of Panic identifies catastrophic misinterpretation of body sensations as a criticial maintenance factor which serves to ... https://www.psychologytools.com/resource/understanding-my-panic/

Information Handout

Assessment

Information

CBT

ACT

Intervention

Presentations

Recommended Reading

Case formulation / Case conceptualization

Cognitive Behavioral Models Of Disorders

What Is Case Conceptualization / Case Formulation?

Types of Case Formulation

Case formulations can vary according to their purpose, and according to the information they attempt to convey. A number of types of formulation have been described:

  • A cross-sectional formulation presents information relevant to a short time period, as though an event were sliced open at a particular moment in time to reveal the triggering event, thoughts (interpretations/appraisals), emotions, body feelings, and behaviors or reactions. One of the most popular formats for a cross-sectional formulation is Padesky and Mooney’s ‘hot cross bun’ (1990).
  • A longitudinal formulation presents information relevant to the origin and maintenance of a problem. Weerasekera’s “Multiperspective model” popularized the use of the “5 Ps” approach (presenting, predisposing, precipitating, perpetuating, and protective) to case formulation (Weerasekera, 1993). Judith Beck’s cognitive conceptualization (1995) links longitudinal factors (including relevant childhood data, core beliefs, conditional assumptions, coping strategies) to cross-sectional breakdowns (situation, automatic thought and appraisal, emotion, behavior).
  • Micro-formulations have been described as a helpful way of understanding the origin and effects of troubling imagery (Hackmann, Bennett-Levy, & Holmes, 2011). In this approach problematic images are explored along with their origin, associated appraisals, current impact, maintenance factors, and cognitive consequences.
  • Disorder-specific models describe the critical presenting, predisposing, precipitating, and perpetuating factors relevant to a condition. Disorder-specific cognitive behavioral conceptualizations have been published for most conditions including low self-esteem, panic, obsessive-compulsive disorder, psychosispost-traumatic stress disorder.

References

  • Beck, J. S. (1995). Cognitive behavior therapy: Basics and beyond. New York: Guilford Press.
  • Butler, G. (1998). Clinical formulation. In A. S. Bellack and M. Hersen (eds) Comprehensive clinical psychology. New York: Pergamon Press
  • Hackmann, A., Bennett-Levy, J., & Holmes, E. A. (2011). Oxford guide to imagery in cognitive therapy. New York: Oxford University Press.
  • Padesky, C. A., & Mooney, K. A. (1990). Presenting the cognitive model to clients. International Cognitive Therapy Newsletter, 6, 13–14.
  • Persons, J. B. (1989). Cognitive therapy in practice: A case formulation approach. New York: WW Norton.
  • Persons, J. (2008). The case formulation approach to cognitive-behavior therapy (guides to individualized evidence-based treatment).
  • Weerasekera, P. (1993). Formulation: A multiperspective model. Canadian Journal of Psychiatry, 38(5), 351–358.