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Case Discussion On Anxiety

Case Discussion On Anxiety

1Clinical Psychologist, Patras Technological Institute, Greece
2New York College, Greece, Health Psychologist – Psychotherapist
Greece 3Counselor

Clinical Psychologist Maria Theodoratou, Technological Institute of Patras, School of Health and Welfare Professions, Patras, Greece

May 5, 2014, | Published on July 12, 2014

M. Theodoratou, P. Andriopoulou, and M. Manousaki (2014) Exam Anxiety: A Case Study. J Clin Psychol Psychiatry 1(4): 00021. DOI: 10.15406/jpcpy.2014.0000021

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The case we will present is about a 28-year-old woman terrified of her upcoming university exams. We find this case particularly intriguing because, despite having interrupted her chemistry studies for four years, she overcame her anxiety, graduated successfully, and pursued further postgraduate studies in the United Kingdom after undergoing cognitive therapy. This article aims to present the patient’s mental map and the procedures that led to the achievement of therapeutic purposes.

Review of the literature
Standard Beckian CBT, also known as cognitive therapy (CT), is based on the mental model, which connects cognitions, emotions, and behaviors in such a way that cognitions shape emotions and behaviors, and unrealistic cognitions can lead to inappropriate feelings and behaviors. 1 CT is a structured or semi-structured approach that is directive, active, and short-term. Its clinical use is applied to a variety of psychiatric disorders, including anxiety, personality, and eating disorders, as well as a variety of crises and conditions associated with the use of psychoactive substances. 2

Most approaches to CI agree on its fundamental principles, which include the following: people develop adaptability. Non-adaptable behaviors and affective patterns through cognitive processes, the functions of these cognitive processes can be activated by the same procedures commonly used in the human learning laboratory. The therapist is a diagnostician and pedagogue who evaluates dysfunctional cognitive processes and arranges such learning experiences.


CT’s goals are to restructure dysfunctional cognitions and provide cognitive flexibility when assessing specific situations and solving focal problems, as well as to provide patients with mental strategies to perceive and functionally respond to the real world.

5 CT is thought to help with issues related to depression and panic disorders, such as verbal and nonverbal communication skills, assertiveness, criticizing and receiving criticism, refusing alcohol, and saying no in general. 6

Describe the problematic behavior

A 28-year-old chemistry student, Helen, sought therapy for severe anxiety about her university exams. According to DSM-IV-TR.7, the diagnostic interview revealed that she had a Specific Phobia (Exams Phobia). She also had anxiety and depressive symptoms. Helen complained about the following during the initial stages of her interview:

She could not attend the lectures or enter the lecture hall (“lecture theatre phobia”). She couldn’t concentrate, study for exams, or take them. She avoided getting too close to the University and anything related to the University. She couldn’t make up her mind whether she wanted to get her degree or not. She was generally anxious about everything. She desired to be flawless in all aspects of her life and was concerned about the opinions of others. She was constantly thinking about University. As a result, she could not enjoy herself and was always depressed. She avoided social situations and, eventually, avoided crowded places. Helen appeared to have the following physiological complaints: permanent headache, insomnia, stomachache, fatigue, loss of energy, drowsiness, and clenching of teeth while sleeping, which resulted in pain. As a result of everything that had happened, she was anxious, disappointed, and depressed.
Case Discussion On Anxiety
Personal and family background

Helen was the family’s second child. There was an older brother (now married) and a younger sister who had completed law school. Her brother seemed to be the source of many problems in the family. He was a rebellious and undisciplined child, dubbed the “problem child” by Helen. Helen could not communicate with her family, and her sister only spoke with her. Helen’s family was low-income, which added to the strain on her shoulders. Helen thought she was good at everything as a student. Her family, on the other hand, she felt was following her. They were watching everything she did and putting pressure on her. Helen’s situation at the time she sought therapy was as follows:

Her sister and father encouraged her to continue her education. They even encouraged her to continue her education. Her father always warned her that if she didn’t finish University, she’d end up working as a maid. “You’re a zero if you don’t have a degree,” he said. Helen had the impression that her father relied on her. “He has substituted me for his son. I was always under the impression that I had to do what he wanted, “She stated. Her sister was constantly criticizing her and labeling her irresponsible. She was also interfering with Helen’s attempts to contact her lecturers to persuade them to be more lenient with her, which enraged Helen.

Helen could only work in the field of foreign languages during her therapy. She was good at them and could study without feeling anxious. Foreign languages were regarded as a hobby rather than “real work” by her. Surprisingly, her parents were uninterested in her language performance and did not put any pressure on her.

To make matters worse, their financial situation was dire, and Helen was still determining whether she should continue her studies or look for work to solve her financial problems. Even though Helen felt like she was suffocating from all her problems, there seemed to be no way out because her parents were ill, and she couldn’t leave the house.

Helen’s parents and sister put too much pressure on her in terms of her studies, as evidenced by the above brief account of her family history. She was pressed and chastised for being unable to complete her studies. Given this, and the rest of her “difficult” family environment, it’s no surprise Helen developed an anxiety disorder.

Rules and assumptions that are dysfunctional

Dysfunctional assumptions and rules are general beliefs that people have about the world and themselves that are said to lead them to interpret specific situations in an excessively negative and dysfunctional manner. Most dysfunctional assumptions or beliefs in anxiety revolve around issues of acceptance, competence, responsibility, control, and anxiety symptoms. 8,9

Helen’s beliefs and assumptions:

“Unless I have a degree, I am nothing.”
“I’m always trying to please my family.”
“I can’t handle the exams,” “If I can’t handle this, I can’t handle anything,” and “I have to do everything perfectly, or else others will look down on me.”
“I’m always doing what my father wants” “Students are snobs, and I don’t want to be like them.”
“I have to be in command at all times.”
“You cannot change what you are accustomed to.”
Helen’s beliefs above triggered several automatic thoughts, including:

I’m unable to enter the lecture hall.
I have no control over this situation.
My parents will never be pleased with me; it is too late for me to change; there is no second chance.
Everything appears to be a mountain, and I am tired of taking exams.
You do not feel inferior if you have a degree.
This degree will always bother me no matter what I do. It is not possible to sit an exam and pass.
My mind isn’t working, and I’m not going to make it because I don’t want to be a snob like the other students.
Distortions in cognition

Its primary cognitive distortions of Helen were stimulus generalization, catastrophizing, and selective abstraction.

10 The variety of stimuli that elicited anxiety expanded, and anything related to the University was perceived as a threat (stimulus generalization). Like many worried people,11 Helen tended to focus on the worst-case scenario. For example, she reasoned, “If I fail the exam, I won’t be able to finish University and will have to work as a cleaner” (catastrophizing).

Finally, Helen appeared aware of her difficulties in dealing with the exam situation but not her assets. As a result, she had a skewed perception of the danger and her vulnerability (selective abstraction).

Figure 1 depicts how the reactions to symptoms perpetuate the phobia by creating vicious circles of fear. Avoidance maintains anxiety because it makes learning that the feared situation (e.g., exams) is not, in fact, hazardous in the way or to the extent that Helen believes it is difficult. Other important sustaining factors include thoughts about the meaning of anxiety symptoms (e.g., “My brains don’t function properly”) or the expected consequences of entering the phobic situation (e.g., “I will fail,” “I will never be able to finish University”), and loss of confidence. 12

Click here to see a larger version of this image.
Figure 1 depicts Helen’s vicious circle. Butler’s 12

Treatment objectives

I explain the cognitive model using Helen’s symptoms to demonstrate how vicious circles maintain signs.
Educating her on how to recognize automatic thoughts and find alternatives
Problem-solving in the context of studying and taking exams
Being able to distinguish herself from her family
Behavioral and cognitive techniques were employed.

“TIC-TOC” technique: Helen could not study due to her negative beliefs about learning and University. The therapist focused on these “Task Inhibited Cognitions” and taught Helen how to monitor, challenge, and replace these dysfunctional cognitions with “Task Oriented Cognitions.” 13. Thus, Helen’s automatic thought, “I am not going to make it,” was substituted with, “If I do not try I have no possibility of succeeding. If I do try though I have at least some possibilities.”

“Graded task assignment”: The goal of this technique was to increase success by breaking tasks down into small, manageable steps.

14 As a result, Helen was assigned minor tasks to complete. For example, she would study a few pages each time to prepare herself for this stressful situation (looking).

“Graded exposure”: Exposure is defined as confronting something that has previously been avoided due to anxiety.

12 Helen was encouraged to talk about University and try to go. As a result, she could visit University and even write down the exam schedule. Finally, she went to the lecture theatre to take an exam, first with the therapist present and then by herself.

“Daily record of dysfunctional thoughts”: Situations preceding unpleasant emotions and emotions and automatic thoughts were recorded. Helen eventually learned how to challenge these thoughts (Table 1 contains an example of Helen’s Daily Record of Dysfunctional Thoughts). It should be noted that Helen was unwilling to do any homework at this point. This was thought to be a contributing factor to her inability to concentrate. As a result, the record forms were filled out during the therapeutic session.


Thoughts That Come To Mind


Reasonable Reaction


Preparing for Exams

“I’m not going to be able to make it.”


“I excel at foreign languages.”


“I don’t believe in myself.”


“If I try, I have a good chance of passing.”

“I’m afraid to take the chance.”

Table 1 shows Helen’s daily journal of dysfunctional thoughts.

Therapeutic accomplishments

Despite treatment difficulties (Helen refused to do homework), the therapeutic results were impressive.
Following five months of therapy, including check-ups:

She was able to decide whether or not she wanted to finish University.
She graduated with honors.
Her physical symptoms vanished.
In the United Kingdom, she pursued postgraduate studies.
This case study presented the main tools for treating anxiety disorders and specific cognitive therapy conceptual frameworks that were used effectively in this patient’s therapy and affected her entire life so that she could lead a well-adjusted life. Last but not least, she mentioned in a follow-up session that she has worked in a company in the United Kingdom for the previous ten years after completing her postgraduate studies.
A 25-year-old male presents to your clinic because he is having difficulty his new job. He works at a consulting firm. He states it is hard for him to give presentations due to concerns that he will embarrass himself and his peers will think less of him. To avoid being put on the spot, he has passed up multiple lead roles and potential promotion as a result. He says this is frustrating because he doesn’t have an issue interacting with peers in small groups or friends and in no work settings.

Summarize the clinical case.
Create a list of the patient’s problems and prioritize them.
Which diagnosis should be considered
What is your rationale for the diagnosis
What differential diagnosis should be considered
What test or screening tools should be considered to help identify the correct diagnosis
What treatment would you prescribe and what is the rationale (consider psychopharmacology, diagnostics tests, referrals, psychotherapy, psychoeducation)
What standard guidelines would you use to assess or treat this patient
Responses need to address all components of the question, demonstrate critical thinking and analysis and include peer-reviewed journal evidence to support the student’s position.

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