Introduction
Mr X is a 19-year-old in his second year at the university struggling with a generalised anxiety disorder (GAD). The problem emerged two years before, and the new university responsibilities made the situation more unbearable. While preparing for his advanced level qualifications (A levels), he struggled with emotions and became nervous whenever a big event came. Symptoms experienced by Mr X included dizziness, feeling lightheaded, trembling, sweaty, and consistently spasmed muscles. He did not consider being abnormally anxious as it was a norm with his peers, who were also stressed and worried about where they will go to pursue higher education. The father had had similar experiences, but the family never discussed the problem. He had to formulate approaches to dealing with the disorder, including drafting his motto. The emergence and persistence of the GAD symptoms forced him to seek professional help.
After talking to a friend, he was advised to see a general practitioner (GP). Mr X did not like the idea as it would involve medication and would prove that he had clinical anxiety levels indicating it was much more severe than he thought. After trying to manage the situation alone by conducting personal research about the health concern, it proved hard as it worsened. Mr X sought help from the GP and enrolled in therapy, where the GAD treatment started. Medication was recommended, and he used it secretly for a while but later relapsed. The doctor continued offering support despite his confessing to stopping the medication use. The doctor provided a new strategy that included making their meeting much more frequent than before to help him overcome the psychological problem.
Understanding the factors that led to the illness and how Mr X coped with them before and during the treatment uses one theory, model, and aspect. The biopsychosocial theory, the cognitive-behavioural model of a generalised anxiety disorder (GAD), and the concept of operant conditioning are referred to in the study. The former will be used to understand how the factors related to the three aspects of the approach are expressed. Important aspects deemed crucial in maintaining GAD are presented under the behavioural model and will be used to analyse how their application is developed in Mr X’s case. Operant conditioning will guide and provide information on the relevance of exposure therapy involving learning and adaptation. All aspects of the identified theory, model, and concept will be critically reviewed under predisposing, precipitating, perpetuating, and protective factors.
Causes of Diagnosis
The Theory, Model, and Concept of Behaviour Change
George Engel conceptualised the Biopsychosocial Theory in 1977, explaining why a medical condition can not be understood through biological factors alone but with psychological and social elements. It includes an individual’s general thinking pattern, environment, and genetics, which get used in trying to explain the effects on behaviour and development of GAD (Peña-Vargas, Armaiz-Peña and Castro-Figueroa, 2021). Mr X expressed several trigger aspects, such as genetic predisposition, high anxiety sensitivity, and social stigma, that led to developing his health concern, incorporating all three elements of the theory.
The cognitive-behavioural model will also be used in understanding the mental illness that Mr X experiences. It outlines four main factors: Intolerance of uncertainty (IoU), positive beliefs about worry, negative problem orientation, and cognitive avoidance (Kuzo, Posokhova and Kuzo, 2021). Negative problem attitude and IoU portray the highest risk of attaining anxiety compared to the remaining components (Mofatteh, 2020). The four constituents try to summarise the treatment of GAD and its impact.
The operant conditioning behavioural principle will be incorporated to understand the effectiveness of self-educating. The concept refers to the learning that occurs due to experiencing punishment or reinforcement due to the actions done (Weerdmeester et al., 2020). This concept contains four significant aspects: reinforcement, generalisation and discrimination, extinction, and spontaneous recovery (Weerdmeester et al., 2020). The first two facets treat the behaviour, and the last two focus on re-occurring controlled habits when particular steps are not followed.
There are several causes of anxiety and those that worsen the condition. The potential elements are grouped into three distinct categories: predisposing, precipitating, and perpetuating events (Zipfel et al., 2022). As presented in the interview, the generalised anxiety disorder (GAD) experienced by Mr X was influenced by particular events like examinations. Additionally, there was a history of illness within the family, as the father also suffered in the past.
Predisposing Factors
Predisposing factors are the areas of vulnerability that escalate the chances of the problem getting established. According to the Biopsychosocial approach, these factors can be found under each of the three aspects, that is, biological, psychological, and sociological components (Zipfel et al., 2022). The identified factors in Mr X’s interviews include genetic makeup, high anxiety sensitivity, and stigma around help-seeking. Mr X states that his father suffered from anxiety way back. As a result, there was a greater chance of him developing the same disease due to their genetic makeup. One common psychological risk factor in mental illness is sensitivity, especially in anxiety, as it can be elevated, thus causing severe repercussions (Fauzi et al., 2021). Mr X complained of experiencing GAD, especially when faced with life-changing events such as examinations that would result in the transmission to another learning phase. The social factor present in his interview is the inability to seek help due to fear. Mr was reluctant to get professional aid as he feared his parents would judge him.
The cognitive model of GAD states that the major causes of this mental illness may arise from the perplexing interaction between environmental and biological facets. Common risk factors likely to result in the development of anxiety include personality, drug misuse, depression, trauma, stress build-up, and genetics (Vîslă, Allemand and Flückiger, 2022). Mr X experienced two potential causes: genetics and stress build-up. A blood relative suffered from anxiety disorder within his family. Given the close family ties with the past victim, his chances of developing the same problem were high. The main trigger that led to his panic behaviour emergence was any life-changing event. Upcoming events like interviews and the General Certificate of Secondary Education (GCSE) made Mr X extremely nervous. The condition worsened, and he started to tremble, feel dizzy, and lightheaded.
The operant conditioning concept can be used to explain how repercussions help develop or eliminate a specific attitude. The theory states that the consequences of a behaviour determine its possibility of getting repeated (Rossiter, 2022). These actions lead to further distress as they interfere with an individual’s life, such as the inability to engage in activities. Mr X became more anxious whenever he was in an interview. As a result, he could not get employment for some time, which affected his psychological well-being. When positive reinforcement is adopted, the behaviour is increased by a reward; when negative reinforcement is used, it is increased by avoidance (Rossiter, 2022). Mr X had anxiety issues whenever big occasions occurred, but he was fine immediately after they passed. From this experience, avoidance is the reward, increasing the attitude of avoiding. Operant conditioning further asserts that escaping anxiety-provoking stimuli can remove all unpleasant emotions (Rossiter, 2022). Since attending significant events triggered Mr X’s anxiety issues, the emergence of this illness was minimal in cases where no such meeting was attended.
Precipitating Factors
Precipitating elements of behavioural change refer to the specific event that triggered and resulted in the onset of the ongoing issue. The biopsychosocial theory asserts that everyday stressors could be positive or negative. These events may include medication non-adherence and academic stressors (Chrisman et al., 2021). Work, educational and financial stressors are examples of social components standard in the contemporary world (Chrisman et al., 2021). Mr X failed to follow the doctor’s instructions and stopped using the medications, resulting in his relapse. The typical social factor likely to have affected him is the education stressor. He was under immense pressure to please the family as he was the first to reach the university level. Mr X feared getting diagnosed as his family would regard him as unworthy of keeping the dream alive.
The first of the four aspects of the cognitive model of GAD is the intolerance of uncertainty (IoU). It is a strong dislike of uncertain situations or those with uncertain outcomes. People with GAD have high IoU as they are overprotective of themselves (Gústavsson, Salkovskis and Sigurðsson, 2021). As stated earlier, Mr X did not want the family involved in his treatment process or even made aware of his situation. Despite getting help and changes getting experienced, he avoided letting anyone know. Under the second factor of this model, positive beliefs about worry, there is the presumption that it prevents bad things from happening (Gústavsson, Salkovskis and Sigurðsson, 2021). Whenever Mr X felt like giving up, he reassured himself with his motto, “I can do this; I can do hard things.” As a prevention strategy, Mr X sought help early after being advised by his friend. His treatment was effective as his anxiety started easing after some time.
The concept of reinforcement presents the leading cause of habit change. Effective use of the medication provided by the doctor made Mr X overcome anxiety. At first, he opted for therapy alone, which proved successful but took much more time. The general practitioner recommended medication use, but he did not like the idea as it meant the illness was genuine. Mr X failed to accept his reality and take the necessary steps to correct the setback. He took medications under extreme secrecy when the condition became more severe and had to seek additional help. The reinforcement at this stage was using drugs, which helped prevent anxiety (Rossiter, 2022). At some point, the drugs ended, and he failed to purchase them as he thought he was saved already.
The positive reinforcement adopted by Mr X was drug use, and once it was not provided, the behaviour change was stalled. Sometimes actions are reinforced for particular triggers, and their absence results in no reinforcement. The generalisation and discrimination aspects of the operant concept can be used to understand this process. Mr X adopted stimulus discrimination when he concluded that only two specific occasions could make him anxious: the exams and job interviews. Similarly, he made a general conclusion that avoiding the two events would make him free from anxiety.
Perpetuating Factors
Perpetuating aspects are those conditions that worsen a situation and maintain the shortcoming once it has been established. According to the biopsychosocial premise, common conditions that cause behaviour change include lack of employment, financial distress, and lack of education (Gilboa-Schechtman, 2020). In anxiety treatment, common factors that may give rise to the persistence of the problem or relapse from treatment include sub-optimal dosing, personality traits, lack of empathy from friends or family, and isolation (Ellis et al., 2021). Mr X identified the lack of support from relatives and peers as they were judgemental. It is impossible to overcome health disparities such as anxiety when working alone as there are high chances of relapsing (Silva et al., 2021). These aspects questioned his personality as he could not establish beneficial interpersonal relationships. Since no one followed up on him, Mr X stopped his medication immediately after the first dose ended.
The third aspect of the cognitive model focuses on an individual’s ability to solve issues they encounter. Mr X believed he could address his anxiety problem alone without help from his family or friends. He opted for only professional service and thought he could manage the rest. Mr X has a social situation with seeking help, prompting him to indulge in the anxiety treatment journey alone. The lack of external assistance from others makes his journey extremely hard as the likeliness of him giving up is high compared to when he has support. The short-term psychotherapy treatment helps manage personal worries and allows one to gradually return to the events avoided due to anxiety (Velden et al., 2020). Combining this treatment and medication is the most effective in treating GAD, although cognitive behavioural therapy is the most effective (Mofatteh, 2020). Mr X adopted the therapy and witnessed changes initially but faced other challenges. He then integrated medication, which proved essential as he relapsed when he stopped using but experienced tremendous transformation.
The operant concept is crucial in realising the perpetuating factors. It focuses on the punishment and reinforcement that facilitate anxiety maintenance and development (Hofmann and Hay, 2018). Mr X used two coping strategies, avoidance, and escape, which played a significant role in anxiety worsening and treatment. After the emergence of GAD during the A levels exams, Mr X started experiencing this disorder much more frequently. Besides examination and interviews, Mr X did not portray other anxiety disorder triggers. The easiest way for him to overcome the shortcomings based on this concept was to distance himself from these two significant events (Hofmann and Hay, 2018). Despite proving helpful, it was unsuccessful in the long term as he was destined to face them repeatedly. Mr X was still in his second year when he was diagnosed. He has more years to encounter examinations and interviews in his life. Mr X disregarded any genetic influence as he reported that he convinced himself everything was fine. According to him, the father always provided for the family and never stopped working despite having the same issue.
Additional Causes
Protective Factors
Protective factors are the elements that protect and help individuals manage stressful events. They lower the likelihood of a negative impact and are viewed as positive countering events. The biopsychosocial model outlines aspects like adequate sleep, reduced drug abuse, high resilience, and stable family dynamics as the significant protective components (Gilboa-Schechtman, 2020). Mr X adopted several of these aspects in his interview about GAD. The first step he took in minimising the effects of anxiety disorder was researching the health problem. Mr X then talked to a friend who suggested visiting a general practitioner. The internet searches hinted at a need to enrol in some therapy. The fourth aspect of the cognitive model fits in such scenarios. The mental avoidance factor describes the strategies victims with GAD use to overcome anxious feelings or thoughts. These procedures include avoiding situations that develop anxiety or suppress worries (Gústavsson, Salkovskis and Sigurðsson, 2021). Mr X tried dealing with the issue by preventing anxiety-triggering events, but that did not last for long as the causes became more and the symptoms worsened.
The extinction and spontaneous recovery aspects of the conditioning approach focus on the extinguished stimulus and the reappearance of the controlled habits. The latter states that a behaviour can be extinct when the conditioned response is stopped (Hofmann and Hay, 2018). When a governed trigger such as avoidance and medication gets annihilated, the constrained reaction will likely re-emerge. Mr X’s anxiety resurfaced when he stopped using the drugs given, but the behaviour was controllable upon medication. The spontaneous recovery aspect was witnessed in this occurrence as the managed behaviour of GAD reappeared. Based on the operant theory, for the protective factors to be successful, the two mentioned aspects must be controlled by ensuring the reinforcement is constant until full recovery is made.
Before making the final decision, Mr X did several other studies that did not satisfy his needs. The recommended treatment from his research was rational emotive therapy, as it was tested and proved effective in treating severe anxiety issues. The reinforcement aspect of operant conditioning influenced his well-being. The general practitioner recommended taking medication to speed up the treatment. The doctor’s supportive nature influenced Mr X’s treatment quest. He was encouraged to share his shortcomings as it helped draft a more sophisticated plan. Knowing medication relevance, Mr X took the treatment programs seriously. Together with the doctor, they set goals on pill taking and how his progress will be tracked using the medication event monitoring system (MEMS) caps.
Conclusion
Before finalising his A levels, Mr X was diagnosed with a generalised anxiety disorder. He is in his second year at the university and still experiences anxiousness challenges. He cannot sit for exams or get interviewed as the situations make him extremely anxious. The biopsychosocial theory, the cognitive-behavioural model, and the operant conditioning concept explain the three major factors that are believed to result in the disorder. The subcategories discussed with the help of the approaches include predisposing, precipitating, and perpetuating factors. Under each section, the theory, model, and concept explain the existing aspects expressed by Mr X. The first segment covers the areas that give rise to the health problem, and the second outlines the specific events that trigger the emergence of anxiety. In the last major category, all conditions which worsen the already developed concern are identified. An additional cause is discussed, covering the protective aspects adopted to help eliminate the problem. The three behavioural change theories are discussed with additional referencing from Mr X’s interviews bearing much weight.
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