Shame often links trauma, attachment threat, avoidance, concealment, anger, self-criticism, and disengagement from care.
Look for
Downcast gaze
Patient language
“There is something wrong with me”
Formulation use
Shame may explain avoidance, anger, withdrawal, or self-attack when the patient feels exposed or dependent.
Rumination may feel like problem-solving but often maintains low mood, shame, threat, and cognitive inflexibility.
Look for
Long repetitive analysis
Patient language
“I keep going over it”
Formulation use
Rumination may maintain distress by keeping attention fixed on negative meanings without corrective action.
Attachment avoidance may appear as self-sufficiency, emotional distance, minimisation of need, or disengagement under relational stress.
Look for
Minimises distress
Patient language
“I do not need anyone”
Formulation use
Attachment avoidance may explain disengagement just when support, closeness, or dependency becomes clinically relevant.
Avoidance reduces distress in the short term but commonly maintains anxiety, trauma responses, functional impairment, and interpersonal narrowing.
Look for
Missed appointments
Patient language
“I just avoid it”
Formulation use
Avoidance may explain why distress persists despite the patient working hard to stay safe.
Dissociation can reduce overwhelming distress during threat but may later impair memory integration, presence, agency, and relational engagement.
Look for
Time loss
Patient language
“I was not really there”
Formulation use
Dissociation may explain sudden disengagement, memory gaps, or emotional numbing when arousal exceeds coping capacity.
Emotional dysregulation is a transdiagnostic formulation mechanism that can amplify impulsivity, interpersonal rupture, avoidance, and risk.
Look for
Rapid affect shifts
Patient language
“It goes from zero to one hundred”
Formulation use
Emotional dysregulation can explain why stress rapidly becomes behavioural, interpersonal, or risk-relevant.
Negative core beliefs bias attention and meaning-making, often linking early experience to current automatic thoughts, affect, and behaviour.
Look for
Global self-statements
Patient language
“I am not good enough”
Formulation use
Negative core beliefs provide a bridge between developmental learning and current interpretations.
Perfectionism can drive achievement but may maintain anxiety, depression, shame, procrastination, avoidance, and burnout.
Look for
All-or-nothing standards
Patient language
“If it is not perfect, it is a failure”
Formulation use
Perfectionism may organise coping around preventing shame, criticism, or loss of worth.
Projection can protect against shame or conflict but may create suspicion, blame, and interpersonal escalation.
Look for
High certainty about others motives
Patient language
“They hate me”
Formulation use
Projection may explain why intolerable self-states are experienced as threats located in other people.