Case formulation: A simplified example continues


My final post on case formulation illustrates the slightly simplified case study that I presented here.
I will be simplifying his presentation again today, to make sure this post isn’t too enormous!

Firstly, we identify the relatively stable phenomena:

  • Pain-related anxiety and avoidance
  • Work disability
  • Depression
  • Pain behaviours

Selected biophysical contributing factors:

  • Initial scaphoid fracture
  • Complex regional pain syndrome type i
  • Reduced range of movement and strength
  • Central sensitisation

Selected psychological contributing factors:

  • Unhelpful beliefs about pain and activity
  • Negative reinforcement from avoiding movements anticipated to be painful
  • Catastrophising
  • Nonadherence to treatment recommendations
  • Anxiety/stress about financial situation and employment

Selected social contributing factors:

  • Inadequate explanations from treatment providers
  • Partner punitive towards his disability
  • Unable to access compensation readily
  • Isolating himself

Proximal causal factors

  • Fracture and fall

Maintaining factors

  • Healthcare providers failing to address fears
  • Family members reinforcing ‘wait until it’s better’
  • Avoidance and pain behaviour reinforcing disability
  • Ineffective case management not addressing precarious work situation

By drawing the relationships between these factors, we can arrive at this sort of diagram:

This leads us to consider what interventions might be helpful…

While we might initially address his beliefs about pain by giving him good explanations about CRPS, and ensuring he understands the purpose of therapy, to help him with his underlying pattern of avoidance may take a lot more work, and it will likely mean using both cognitive and operant strategies.  We will need to help him develop good self regulation skills (perhaps through biofeedback to reduce physiological arousal) so he can develop confidence that he can approach feared situations.  We may not directly influence his central sensitisation, but it may be helped through medication and through gradually increasing his approach behaviour.  We will also need to help him understand how avoidance is maintaining his disability, and that it is possible to gradually build his confidence to approach feared situations across many areas of his life by appropriate self regulation including goal setting and problem solving.

Although using a case formulation approach may initially take a little while to carry out, it does provide multiple areas for intervention, and it enables the person with pain to be part of the process.  I hope you’ve enjoyed this series!  If you have, and you want to read more – click the RSS button above or bookmark this site.  I love comments, and reply to them(!), so please feel free to leave a comment either to agree or not.  If you want me to post on something specific, you can email me via the comments area in the ‘About’ section.

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