More re Gary's Thoughts and Beliefs

• The Case of Gary II: Things become more complex. by Jim Pretzer, 9/11/97
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    • Why label if you don't have to? by Paul Salkovskis, 10/1/97
      
      

In response to the request for more detailed information about my assessment of Gary's thoughts, beliefs and responses to specific situations, here is a summary of what I had learned up to this point.

The initial session was taken up by Gary describing his current problems, my obtaining background information, discussing his questions about therapy, and agreeing on our initial goals for therapy. We did not have time to explore his responses to specific situations in any detail.

In the second session we spent part of the time on progressive relaxation and spent the rest of the time with Gary filling me in on his worries:

• re his Irritable Bowel - "Will I have diarrhea?" "Will I have an accident?" (anticipating that he might well have an accident even though this had never happened before)
• re school - "How well will I do?" (anticipating that he would do poorly on most assignments and exams despite previous successes)
• re money - (anticipating financial hardship even though he was well paid and had savings and investments which would generally be considered to be more than adequate)
• re his girlfriend - "Will she leave me?" (She gave mild indications of dissatisfaction at times but his concerns seemed disproportionate)
• re work - "Will I make a mistake?" "If I make a mistake someone could die." (He had not made significant mistakes in the past and there was no obvious reason to believe that he was likely to do so)

Between the second and third sessions Gary tried to write down the situation, his thoughts, and his feelings whenever he noticed his level of anxiety rising or his physical symptoms becoming worse. He recorded his reactions on six different occasions. One typical example was an evening when he was asleep and was awakened by a phone call from his girlfriend. He reported feeling strong fear (he rated the intensity as 80% where 100% is the strongest fear he has ever experienced) and reported that his thoughts were "Will I have to go to the bathroom (due to IBS)?" "I have to get off the phone!" When we discussed the situation further he explained that he feared that if he stayed on the phone he would have uncontrolled diarrhea. He also feared that if he got off the phone abruptly without explanation his girlfriend would get angry with him but he was too embarassed about his IBS to explain.

In the fourth session he mentioned that, as a result of his worries about making mistakes, he constantly checked and rechecked his work and consequently was slow, inefficient, and stressed at work. He reported that his central fear was "If I make a mistake, somebody might die" and that he believed that the way to avoid mistakes was to double-check his work. His biggest concern re making a mistake and having a patient die was that others would then see him as a "fuck-up" and as "incompetent." (Coincidentally, he seemed to fall on the borderline between GAD and OCD which Paul referred to earlier. He also reported mild compulsive checking of faucets and light switches as well)

In the sixth session, part of our time was spent dissecting his reactions to an upcoming class presentation. The relaxation techniques and techniques for coping with worries which he had been working on were helpful but he still experienced moderate anxiety and a tendency to worry. Initially he was unable to identify what he found so threatening about a mundane class presentation, then he described a long-standing fear of being thought dumb. In discussing this he said "dumb people just don't get ahead." He went on to say emphatically that he didn't want people to think "He's just a doctor" and said "I want to be the boss." A few minutes later he explained that his Mom was the boss in his family and said "If you're not the boss you have no control."

This brings us to the sixth session which I've described above. Stay tuned for subsequent developments.

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