Persistent tic disorders (PTDs), including Tourette’s Disorder (TD), involve motor and/or vocal tics and often cause significant impairment and distress for affected individuals and families. Functional impairment is typically greater among individuals with PTDs and comorbid disorders. The current gold standard behavioral intervention for tic disorders, Comprehensive Behavioral Intervention for Tics (CBIT), has demonstrated efficacy in randomized clinical trials. Complications introduced by comorbidities, however, potentially facilitate less optimal long-term outcomes using this treatment approach. This case study describes the implementation of CBIT and subsequent modularized parent training for an 8-year-old boy diagnosed with TD who also exhibited comorbid symptoms of inattention, hyperactivity, and oppositional behavior. Emphasis is placed on delineating treatment decisions, including the sequencing of specific techniques, in accord with algorithms for complicated PTD presentations discussed in the literature.
Although the majority of Veterans are overweight or obese, and many have comorbid mental health disorders, little is known about the most effective way to intervene in this complex population. This case describes a telephone-based cognitive-behavioral treatment for depression and weight management with an obese Veteran with bipolar disorder. His wife joined sessions to leverage spousal support. The Veteran evidenced variable levels of physical activity and mood fluctuations during treatment; although he reported some degree of positive behavior change and improved social support, he did not lose weight. He continued to endorse moderate levels of depressive symptomatology at the end of the nine-session intervention. This case illustrates the complexity of treating those with chronic serious mental illness and multimorbidities. Further research is needed to inform interventions that concurrently improve mental health symptomatology and weight-related outcomes in chronic, complex cases.
Poor sleep quality is more common in patients with multiple sclerosis (MS) than in the general population and is associated with greater disease severity, pain, and poorer quality of life. However, despite its prevalence, sleep problems frequently go untreated or are managed with sleep medication which can be ineffective in the long term and is associated with daytime fatigue and tolerance. In this case study, an individual with MS who had been experiencing sleep problems and had reported dependency on sleep medication was treated with a Cognitive Behavioral Therapy for Insomnia (CBT-I) program over the course of 3 months, with the goal of improving sleep quality while reducing sleep medication. By the end of the treatment, subjective sleep quality had improved, as measured by the Pittsburgh Sleep Quality Index and a sleep diary. Over the course of the treatment, the patient reduced his sleep medication to nil until he was sleeping with no sleep disturbance. Self-reported sleep measures at follow-up showed that these improvements in sleep quality had remained. In addition, scores on self-reported measures of life satisfaction, impact of MS on physical and psychological functioning, and anxiety and depression scores all showed improvements from assessment to follow-up. This case study illustrates a potential non-pharmaceutical treatment option for sleep problems for individuals with MS which is evidence-based in the general population and other comorbid conditions.
Adults with developmental disabilities are particularly vulnerable to experiencing obsessive-compulsive disorder (OCD). However, the application of evidence-based treatments such as Exposure and Response Prevention (ERP) to individuals with comorbid OCD and developmental disabilities is a relatively new and emerging field of study. The present article presents a case study of modified ERP for the treatment of an adult woman with comorbid OCD-like repetitive behavior and developmental disabilities. Target behaviors, including OCD-like repetitive behavior, verbal agitation, and physical aggression, decreased over the course of the 7-month active treatment phase, and reductions in physical aggression and verbal agitation were maintained during follow-up. This case study provides important lessons about the individual-level and systems-level assessment and treatment of comorbid OCD-like repetitive behavior and developmental disabilities.
We report the case of a 7-year-old boy who had autism spectrum disorder and displayed disruptive and avoidant behavior when using the bathroom at home with people present in adjoining rooms or nearby the bathroom door. Desensitization treatment was implemented by gradually exposing the boy to proximity of an in-home therapist when he was in the bathroom and positively reinforcing the absence of disruptive behavior. Treatment effectively eliminated bathroom avoidance and generalized to settings outside the home. Intervention outcome was maintained 6- and 7-months post-treatment.
Disruptive mood dysregulation disorder (DMDD) is a relatively new diagnosis in the field of childhood onset disorders. Characterized by both behavior and mood disruption, DMDD is a purportedly unique clinical presentation with few relevant treatment studies to date. The current case study presents the application of cognitive-behavioral therapy (CBT) for anger and aggression in a 9-year-old girl with DMDD, co-occurring attention deficit hyperactivity disorder (ADHD), and a history of unspecified anxiety disorder. At the time of intake evaluation, she demonstrated three to four temper outbursts and two to three episodes of aggressive behavior per week, in addition to prolonged displays of non-episodic irritability lasting hours or days at a time. A total of 12 CBT sessions were conducted over 12 weeks and 5 follow-up booster sessions were completed over a subsequent 3-month period. Irritability-related material was specially designed to target the DMDD clinical presentation. Post-treatment and 3-month follow-up assessments, including independent evaluation, demonstrated significant decreases in the target symptoms of anger, aggression, and irritability. Although the complexities of diagnosing and treating DMDD warrant extensive research inquiry, the current case study suggests CBT for anger and aggression as a viable treatment for affected youth.
The scarcity of accessible culturally competent service providers and a general sense of mistrust in Eurocentric-based mental health settings exacerbate the lack of help seeking and effective therapeutic engagement for Latinos. Thus, clinical interventions that account for diverse values and worldviews may be an important step in the helpful treatment of U.S. Latino populations. Behavioral activation (BA), an evidence-based intervention for the treatment of depression, was recently evaluated through a preliminary clinical trial study in a community clinic primarily serving Spanish-speaking Latinos, and the results were promising. A culturally adapted version of BA was developed for Latinos, which took into consideration the cultural value of familismo (a collectivist worldview and preference for maintaining close connections to family); however, BA has not been previously applied to Latino families. The current case study presents the clinical treatment of a Mexican American family living in the southwest of the United States experiencing numerous stressors resulting in depressive symptoms. Specifically, this family sought therapy having experienced many negative life events, including stressors associated with institutionalized racism, their financial situation, and acculturation process. This led to a disruption of the family hierarchy, anger, unhappiness, fear, and isolation among family members. Outcomes of the intervention include a decrease in depressive symptoms and improved family communication and relationships by their involvement in activities such as attending cultural events in their community, family outings, and the children’s participation in extracurricular activities.
Intimate partner violence has been associated with long-term negative effects on mothers’ mental health status, use of positive parenting practices, and their children’s externalizing behavioral difficulties. Especially strong is the association between concurrent experiences of partner violence and maternal parenting. In this case study, we examined the impact of behavioral parent training on parenting and outcomes for a 6-year-old Latino diagnosed with oppositional defiant disorder (ODD). The family was participating in a larger study examining the implementation and cultural adaptations of an evidence-based parent training program, Helping the Noncompliant Child. Mother reported a history of domestic violence and ongoing abusive behavior from her intimate partner but only wanted services focused on addressing child’s behavioral difficulties and improving the quality of parent–child interactions. Adaptations included but were not limited to the translation of all intervention materials, extending the number of sessions focused on each parenting strategy, flexibility with regard to the location and time of therapy sessions, negotiating safe times for the family to participate in treatment, and case management. Parent reports of child behavior and parenting stress moved from the clinical range to the normal range from pre- to post-test. Mother also reported increased use of positive parenting practices. These data, along with closing semi-structured interviews, suggest that within the context of ongoing partner abuse, a mother’s parenting and her child’s behavior can be positively affected by parent training that is adapted and responsive to the context of their family’s situation.
This group case study describes the course of a 14-session Cognitive-Behavioral Therapy (CBT) for Latino adolescents with type 1 diabetes mellitus (T1DM) and depressive symptoms. The intervention, known as CBT-DM, is an adaptation of an efficacious group intervention for adolescent depression. The treatment rationale and cultural adaption model are described, as well as procedures used to achieve sensitivity to the characteristics of the T1DM culture as experienced by Latino youth from Puerto Rico. Session-by-session protocol is reviewed, and treatment gains on the group as a whole and on its individual members are presented, providing quantitative and qualitative data. Treatment feasibility, clients’ acceptance and satisfaction with treatment, and follow-up data up to 6 months post-treatment are also examined, considering cognitive, behavioral, emotional, relational, medical, and functional outcomes. Complicating factors, barriers to care, and treatment implications are discussed in the context of treating clients with comorbid chronic physical illness and emotional problems also embedded in a Latino culture. Translation of evidence-based treatments for depression into primary care settings and adapting protocols to youth populations with other medical illnesses is proposed. Recommendations for clinicians are provided, emphasizing the establishment of collaborative relationships with clients, assessing their stage in the process of accepting their chronic illness, as well as understanding their overall context to avoid unnecessary attributions of pathology to their thoughts, behaviors, and feelings.
Limited information exists on the application of evidence-based treatments for eating disorders among diverse populations. An increasing number of international and immigrant clients provides a pressing need for culturally responsive treatments. This case study highlights an eating disorder treatment that incorporates dialectical behavior therapy and cultural adaptation guidelines. This study explicates a culturally adapted dialectical behavior therapy (DBT) treatment of a 24-year-old female Chinese international student suffering from an eating disorder, depression, and cultural adjustment issues. In particular, this case addresses Chinese cultural values, including conformity, interdependence, and filial piety, and how these values intersect with the client’s presenting issues and treatment. Cultural modifications made to the case conceptualization and dialectical behavior therapy are discussed. The client reported a significant decrease in distress, an increase in the quality of social relationships, and an increase in satisfaction with social roles. These results provide support for the effectiveness and importance of integrating cultural adaptation and evidence-based treatment. Clinical implications and recommendations for clinicians and students are provided.
American Indian/Alaska Native (AI/AN) youth have higher rates of suicidality than any other ethnic or cultural group in the United States. Dialectical behavior therapy (DBT) is an evidence-based treatment that has been found to reduce suicidality in adolescents, but there is little literature speaking to its efficacy with the AI/AN population. The transactional-ecological model of suicidality helps identify protective factors that can be bolstered at the individual, familial, community, and spiritual levels to reduce suicidality and suicidal contagion in AI/AN youth. The current study examines a case where DBT was culturally adapted and embedded within a transactional-ecological framework to treat a 14-year-old Navajo female with Major Depressive Disorder with psychotic features who presented to a psychiatric inpatient facility following a suicide attempt. The patient’s wish to die was motivated by her belief that her death could lead to positive changes in an extended family system plagued by historical trauma, alcoholism, suicide, and domestic violence. Ongoing assessment was conducted using the Suicide Status Form (SSF), Suicide Probability Scale (SPS), Reasons for Living Scale for Adolescents (RFL-A), and the DBT diary card. Navajo healing traditions were used in conjunction with DBT skills training and enhancement of ecological protective factors. Initial reduction in depression and suicidality was complicated by an increase in homicidal ideation. A comprehensive psychiatric evaluation was completed, and treatment was modified through medication changes, increased mindfulness practice, bolstering support systems, and engagement in a Navajo healing ceremony. Implications for clinicians treating suicidality in Navajo youth are discussed.
This article describes the brief treatment of a Mexican American teenager who presented for family therapy to address major depressive disorder (MDD) and comorbid binge-purge behaviors. Treatment was brief and integrated components of family-based therapy (LeGrange, 2010) and narrative therapy with an overarching multicultural lens. Progress was measured through self-report (Children’s Depression Inventory), parent-report, and concrete behavioral markers (e.g., reduced number of purging events). By the end of treatment, there was a reduction of depressive symptoms (e.g., elimination of suicidal ideation and cutting behaviors, reduction of fatigue, anhedonia, and low mood) as well as disrupted eating behaviors. By supporting the teenager and family to identify and leverage their individual and family strengths, treatment also strengthened family communication, increased shared positive family experiences (e.g., family meals), and supported the teenager in engaging in community activities consistent with the family’s values. This case adds to the existing literature by reviewing ways in which treatment was modified across multiple domains to provide culturally sensitive care, as well as by identifying weaknesses in the approach, which may serve to illuminate gaps in the existing literature and highlight areas where clinicians may want to adapt their treatment so as to strengthen client outcomes.
This case study follows an 8-year-old Caucasian female who presented with symptoms of Generalized Anxiety Disorder (GAD). Given this child’s age but advanced cognitive skills, careful selection of an appropriate treatment was made. In the current case study, a family-based cognitive–behavioral therapy intervention (Wood & McLeod, 2008) was implemented to treat this child’s symptoms of GAD. Following completion of the intervention, the child demonstrated significant decreases in her symptoms. In addition, she demonstrated a thorough understanding of coping skills, successfully applied and generalized her skills to a variety of situations, and took pride in teaching her skills to others. This child showed quantitative improvements on objective self-report measures as well as qualitative improvements in her overall emotional and behavioral functioning. This case study suggested that cognitive–behavioral therapy interventions, particularly when used in a family-based approach, are effective for children with symptoms of GAD.
This case study provides an analysis of culturally responsive cognitive behavioral therapy with a 15-year-old African American female. The focus of this case study is on the course of treatment and how it was influenced by the implementation of the Jones Intentional Multicultural Interview Schedule (JIMIS)—a process that was completed at the beginning of treatment. A total of 20 therapy sessions were recorded and transcribed for the analysis. The research team analyzed the data qualitatively by identifying culturally salient codes that were stated within each session and coding transcripts using Dedoose software version 6.1.18. Results showed that four culturally salient codes were prominent throughout treatment and that these codes were strongly related to African American culture: gender norms, informal kinship, socioeconomic status, and race/ethnicity. The connections between the coded themes, the cultural values of the client, as well as the implications for treatment outcomes are described. This study provides evidence of the value of initiating discussion of cultural factors at the beginning of treatment to shape the direction of evidence-based treatment. The study also suggests that integrating cultural factors with African American clients is important and does not reduce the quality of care or diminish from the fidelity of the evidence-based treatment. Based on these findings, recommendations for researchers and clinicians are also discussed.
Borderline personality disorder (BPD) is regarded as one of the more difficult clinical presentations to treat, and psychotherapy provides the best outcomes for those suffering with BPD. Dialectical behavioral therapy (DBT) and schema-focused therapy (SFT) are two of the most common evidenced-based treatments for borderline pathology. While these treatments are often used individually, some theorists argue that blended approaches to care could provide more benefit to some clients than just one treatment package alone. The present case study illustrates a blended approach to the treatment of BPD. Specifically, DBT and SFT were used in consort to treat "Luisa," a 34-year-old biracial woman of Caucasian and Hispanic descent who struggled with longstanding interpersonal distress, emotional lability, and identity disturbance. Her treatment course is described in detail, and the implications of this approach to care are discussed.
Trichotillomania (TTM) involves the compulsive pulling of one’s bodily hair and is often associated with significant distress or impairment. The present case study concerns a college-aged woman, whose history of TTM extended over 5 years and had been unsuccessfully treated by psychotherapy and medication management. Although TTM can be a challenging disorder to treat, the literature indicates that cognitive-behavioral therapy (CBT) has been successful in this regard. Therefore, we implemented CBT based on the manual developed by Keuthen, Stein, and Christenson; specific elements of therapy used included relaxation, self-monitoring, habit reversal training (HRT), reinforcement/punishment contingencies, thought monitoring, and cognitive restructuring. This approach was successful, as the client evidenced a 72% decrease in hair-pulling after using HRT alone, and complete elimination of hair-pulling after introducing the cognitive-restructuring element. Impressively, the gains lasted not only in the short term, but also had been reportedly maintained at a 5-year follow-up.
Family-based therapy (FBT) is the evidence-based treatment of choice for anorexia nervosa (AN) in adolescents, with numerous studies providing support for its efficacy in the outpatient realm. This case report describes the application of a brief FBT intervention during an inpatient medical admission for an adolescent presenting with medical instability secondary to new onset AN. The intensive, four-session FBT-guided intervention included (a) psychoeducation and illness externalization, (b) parent skills training, (c) meal coaching, and (d) behavioral contracting. Self-report assessment and anthropometric data collected at pre-, post-, and 5 months following the intervention suggest increase in body mass index (BMI) and percent ideal body weight, increased parental understanding of AN and parental self-efficacy in managing the illness, decreased parent emotional burden of the illness, and decreases in overall adolescent Eating Disorder Examination Questionnaire (EDE-Q) scores. This case report provides preliminary evidence for the acceptability and effectiveness of a brief FBT-based intervention during medical stabilization for adolescents with AN and their families before proceeding to outpatient FBT.
Given the long-term negative outcomes associated with depression in adolescence, there is a pressing need to develop brief, evidence-based treatments that are accessible to more young people experiencing low mood. Behavioral Activation (BA) is an effective treatment for adult depression; however, little research has focused on the use of BA with depressed adolescents, particularly with briefer forms of BA. In this article, we outline an adaptation of brief Behavioral Activation Treatment of Depression (BATD) designed for adolescents and delivered in eight sessions (Brief BA). This case example illustrates how a structured, brief intervention was useful for a depressed young person with a number of complicating and risk factors.
Emetophobia is an understudied specific phobia, especially during the developmental stage of adolescence. Adult and child literatures suggest that a combined approach of psychopharmacological and cognitive-behavioral interventions may be an efficacious treatment for emetophobia. Despite evidence supporting the success of this therapeutic approach, research assessing treatment outcomes of adolescent populations with the disorder remains limited. The current study presents a case study of the successful use of combined treatment for emetophobia in an adolescent female. Therapy included psychoeducation, cognitive restructuring, and exposure therapy in tandem with Sertraline 50 mg. Upon termination of therapeutic services, symptoms of emetophobia were significantly reduced, panic attacks had remitted, and the continued use of psychotropic medication was no longer indicated. Findings in the present case study suggest that cognitive-behavioral therapy (CBT) including exposure-based therapy effectively reduced emetophobia symptoms and panic attacks for the patient. The implications for these findings in treating adolescents with emetophobia are discussed.
This clinical case describes the assessment and treatment of Roger, a 31-year-old veteran who served in Operation Iraqi Freedom. In addition to combat-related post-traumatic stress disorder (PTSD), Roger presented with a conversion disorder (globus pharyngeus) and avoidance of consuming solid food without also consuming alcohol. A multicomponent treatment program for PTSD, trauma management therapy (TMT), was provided 5 times per week over a 3-week period. TMT included daily-exposure therapy (EXP) as well as daily social and emotion regulation (SER) group therapy to target anger, social withdrawal, and depression. In addition to TMT, exposure to food consumption in the absence of alcohol was provided in the final week. PTSD symptoms were assessed via semi-structured interview and self-report measures, while food intake was assessed via behavioral observation. PTSD symptoms as measured by the Clinician-Administered PTSD Scale (CAPS) decreased from 63 at pre-treatment to 17 at post-treatment, indicating that Roger no longer met criteria for PTSD. Exposure to food intake was equally successful with Roger consuming full meals (e.g., hamburger and french fries) without consuming alcohol. This case study exemplifies the successful use of intensive exposure therapy to target comorbid anxiety-based disorders in a short period.
Despite a high prevalence of comorbid disorders such as major depressive disorder (MDD), the empirical guidelines for how to manage co-occurring conditions in the treatment of posttraumatic stress disorder (PTSD) are lacking. In the context of a complicated presentation of PTSD, this case illustration demonstrates the application of an integrated treatment approach with "Amanda," a 28-year-old female with a history of multiple traumas, undiagnosed PTSD for 10 years, and comorbid MDD. In addition, Amanda began having suicidal thoughts mid-treatment. This case study demonstrates how the integration of coping skills training and cognitive processing therapy, in conjunction with prolonged exposure, helped Amanda successfully complete treatment and be able to discuss her traumatic events with minimal distress. At discharge, Amanda no longer met criteria for PTSD, had experienced significant improvements in depression and anxiety symptoms, and was no longer experiencing suicidal thoughts. These improvements were maintained at both 3 and 6 months post treatment.
This is a single-case study of an obese African American female Veteran who has posttraumatic stress disorder (PTSD) and depression. Her presenting psychological symptoms included clinically significant night terrors, insomnia, low self-worth, low motivation, and social isolation. Poor dietary and physical activity responses to her psychological symptoms contributed to her weight gain, as well as interfered with weight-loss efforts. A telephone-based cognitive behavioral treatment integrating mental and behavioral health principles was provided. Over the course of eight sessions, the Veteran learned psychological symptom and behavioral monitoring, thought stopping, cognitive restructuring, deep breathing, calming thoughts, social support, sleep hygiene, and problem-solving skills. Client-centered PTSD and weight-management treatment goals were integrated into each session. The client evidenced weight loss, improved dietary and physical activity habits, and experienced a reduction in PTSD and depression symptoms. This case study demonstrates that an integrated cognitive behavioral treatment approach can be beneficial for decreasing PTSD and depression barriers to weight loss.
This case study describes the use of cognitive-behavioral therapy (CBT) for a 7-year-old girl, "Lauren," who was diagnosed with social anxiety disorder (SAD) and was experiencing significant family stress. Manualized CBT was conducted and substantial reductions in SAD symptoms and impairment were demonstrated. Given additional difficulties remaining in the home setting, booster sessions were continued following manualized treatment to target Lauren’s functioning at home. These follow-up sessions were associated with maintained functioning, and only minimal additional benefits emerged. This case study calls attention to the importance of considering family stress in individual CBT for children with SAD, as well as the difficulties associated with addressing family stress in CBT for SAD. Existing treatments do not routinely address family stress in the context of child SAD, despite the potential to enhance CBT outcomes for children with SAD.
Empirical support exists for behaviorally oriented psychosocial interventions to reduce functional impairment related to autism spectrum disorder (ASD) symptoms in young children, but little research exists examining the effectiveness of such treatments when applied to preschool-aged children with comorbid anxiety symptoms. With this in mind, the authors report on the case of "Marcus," a 4-year-old boy with autistic disorder and impairing comorbid anxiety. Marcus participated in 8 weekly sessions of family-based cognitive-behavioral therapy, addressing his fear-based avoidance of social interactions and sensory stimuli, using an anxiety treatment protocol for youth with ASD modified to account for his young age. This protocol consisted of modular components addressing affective education, exposure, cognitive restructuring, and social coaching. At post-treatment assessment, Marcus exhibited markedly decreased impairment, as evidenced by parent responses to clinical interview and rating scales. In addition, Marcus displayed improvement in severity of anxiety symptoms as illustrated by a decrease in his scores on the Pediatric Anxiety Rating Scale from 17 at baseline to 8 at post-treatment. Therapeutic gains were maintained at 4-month follow-up. Implications and clinical considerations are discussed.
A significant proportion of children exposed to intimate partner violence (IPV) are preschool-aged, yet few interventions exist for this population. Those interventions that do exist focus primarily on reducing psychopathology, without addressing the range of potential outcomes, including resilient functioning. This case study considers the treatment of Alexis, a 6-year-old, African American girl who was referred for services following exposure to IPV. At her initial intake, she not only showed evidence of posttraumatic stress but also exhibited characteristics of resilient functioning. Over the course of a 10-session group intervention, Alexis’s resilient functioning improved, according to both therapist and maternal report. At follow-up, her posttraumatic stress symptoms were below the clinical range, indicating improvement in psychopathology paralleling her increases in resilient functioning. This case lends support for the use of group interventions with young children exposed to violence and also emphasizes the importance of assessing multiple domains of functioning, including resilient behaviors.
In the presented case, "Daryl" experienced 12 hr of uncertainty regarding the safety of a friend before learning the friend was killed during the April 16th shootings at Virginia Tech. Treatment began 4 years following the shootings. Daryl has two previous premature terminations, was treatment resistant, and at high risk for dropping out. Prolonged exposure (PE) was postponed for nine sessions while comprehensive assessment and psychoeducation occurred. PE took place over 15 sessions, with follow-ups occurring at 3, 6, and 12 months following treatment. During PE, a second shooting and accompanying deteriorating sleep led to brief pauses and modification of treatment. Daryl showed marked reduction of posttraumatic stress disorder (PTSD) symptoms throughout the course of treatment, resulting in complete remission of PTSD at the end of formal treatment as he maintained gains during follow-ups. The case study demonstrates the usefulness of symptom monitoring, specific modifications used within treatment, and the importance of assessing for preparedness for treatment.
About one in six children has one or more developmental disabilities, which include autism spectrum disorder (ASD) and intellectual disabilities (ID). Individuals with both ASD and ID are at higher risk of epilepsy, and those with younger onset of seizures are at higher risk of both developmental and behavioral disorders. Young children presenting with developmental and behavioral challenges are often very difficult for caregivers to manage, and challenging behavior results in reduced learning opportunities. Finding effective and efficient interventions to address behavioral issues remains a clinical priority to improve overall outcomes for all children and especially those with developmental disabilities. This case study presents the treatment of a 5-year-old girl diagnosed with ASD, ID, and comorbid epilepsy using Parent–Child Interaction Therapy (PCIT) combined with visual supports (VS). Findings from this case report documented (a) an improvement in behavioral functioning in home, school, and community settings; (b) evidence for the effectiveness of parent-mediated intervention; and (c) support for collaboration and care coordination to improve intervention outcomes.
Although empirically supported treatments for posttraumatic stress disorder (PTSD) and depression have been available for some time, many Mandarin-speaking Chinese immigrants who seek treatment do not receive such services due to living in rural areas. Fortunately, advances in videoconferencing-based technologies are improving rural trauma survivors’ access to remote specialty clinics. Presently, little is known about feasibility and efficacy of psychotherapy provided through distance technologies for clients unable to access local services in their native languages. The present two case studies attempt to partially address this void by providing an account of treatment implemented via videoconferencing with two Mandarin-speaking women from a small Wyoming town. Not only was therapy effective in reducing the severity of PTSD and depressive symptoms for both clients, but treatment gains were also maintained for 4 months following therapy. Connecting and effectively treating two Mandarin-speaking clients using telehealth compellingly demonstrated innovations to expand services and tailor treatments.
Selective mutism (SM) is a relatively uncommon disorder in childhood, occurring in only 0.3 to 1.8 children per thousand. In early childhood, diagnosing SM can be particularly challenging, and the condition often goes unrecognized until the school years. Given the potential comorbidity of anxiety and communication deficits, treatment can be challenging and attendance in early childhood educational programs allows intervention in a contextually sensitive way that may also help address comorbidities and promote generalization. Thus, this case study of an African American preschool boy highlights the unique obstacles and opportunities of assessment and treatment in a preschool setting. Furthermore, we describe a three-step behavioral approach to addressing SM in collaboration with educators over a 3-month period. Substantive research indicates that early intervention with SM is associated with decreased likelihood of developing an anxiety-related disorder later in childhood; therefore, tailored assessment and intervention in early childhood within a community-based setting may be extremely useful.
This is a single case study utilizing time-series analysis for a young adult man with major depressive disorder and dysthymic disorder (i.e., double depression [DD]) and intermittent explosive disorder (IED). Treatment consisted of long-term psychodynamic psychotherapy (LTPP) with an emphasis on facilitating emotional expression and fostering autonomy. During 13 months of therapy, the patient completed daily measures related to his presenting complaint, including overall distress and episodes of rage. These data were examined for clinically significant change across baseline and two phases of treatment using Simulation Modeling Analysis for time-series data. Results indicated improvement in overall distress and in rage episodes. In addition to daily measures, the patient completed a measure of general psychological functioning at monthly intervals throughout treatment, the results of which indicated no reliable change. Complicating factors and implications of treatment are discussed, including the efficacy of LTPP in the treatment of DD and IED.
Many parents who have children suffering from some form of chronic illness or mental disorder may experience chronic stress reactions of various types. Cognitive behavioral therapy (CBT) has been proved to be effective in reducing stress-related problems, but there seems to be no study to date in which CBT has been tested on this specific parent group. Two case studies were therefore performed. Case 1 centered on a 47-year-old married woman, who has lived in Sweden for 12 months. She described how she had become increasingly exhausted, and she wanted help to find strategies enabling her to cope with everyday life. Case 2 featured a 45-year-old single mother, who had been on part-time sick leave due to depression and stress. She described how she had always been anxious and worried and had had two episodes of depression. Both women had sons diagnosed with autism/Asperger syndrome. One of the women met the criteria for pathological burnout, while the other woman was just below the limit. The focus of the therapy for both women was on exhaustion, depression, and sleeping difficulties. In addition, therapy in Case 1 involved under-stimulation and in Case 2, anxiety. When the therapy ended, genuine improvements were registered for both clients. The results show that CBT can be an effective treatment of symptoms for this group of parents so that they can provide adequate support to their children, thus facilitating everyday life for a child with a chronic illness or disorder.
Treatment initiation and engagement of clients with posttraumatic stress disorder (PTSD) can be challenging due to early treatment dropout when a client with PTSD is unwilling to confront feared trauma-related stimuli and experience anxious arousal during exposure. Increased attention to these engagement issues is especially warranted with traditionally underserved populations (i.e., ethnic minorities, low socioeconomic status, rural residence). This case study describes Victor, a 34-year-old Latino man victimized during a robbery in the rural Southeastern United States, and explains the successful cultural modifications made to Victor’s 10 sessions of prolonged exposure (PE) therapy. Telemedicine, or conducting therapy sessions over a secure Internet connection, was used to overcome barriers associated with rural clients with limited access to specialized and bilingual services. Victor showed marked reductions in PTSD symptoms after completion of PE via telemedicine. This article explains the client’s presenting complaints, history, assessment, barriers to care, cultural modifications, and treatment implications.
Little empirical information is established about synthetic marijuana, including the treatment of related disorders. Similar to organic marijuana, chronic synthetic use can lead to a variety of functional impairments, including diminished academic and workplace productivity and performance. Many traditional approaches emphasize treating co-occurring disorders separately, but the present case examines concurrent treatment for Diagnostic and Statistical Manual of Mental Disorders (4th ed., DSM-IV) Synthetic Marijuana Dependence and Generalized Anxiety Disorder by using Motivational Interviewing (MI) and Relapse Prevention (RP) in conjunction with an adapted form of Dialectical Behavior Therapy (DBT). A model for treatment and its potential effects are discussed.
Posttraumatic stress disorder (PTSD) is a mental disorder that is known to have deleterious psychological, physical, and social impacts on individuals. Recognition of PTSD in older adults is difficult due to the complicated presentation taking into account that PTSD symptoms may be masked by other psychiatric and/or somatic diagnoses that are more common in older adults. Furthermore, some older adults may underreport their PTSD symptoms, and the relationship between current symptoms and distant traumas may be difficult to detect. Limited empirical research has been done on the manifestation, course, and treatment of PTSD in older adults. In this article, the literature on PTSD in older adults is reviewed, including discussion of common diagnostic problems, illustrated by a case report of an older woman with late-onset PTSD after a cerebral vascular accident (CVA). In conclusion, identifying PTSD in older adults can be difficult. However, detecting PTSD in older adults is critically important so that possibly hidden or masked trauma symptoms can be addressed in treatment, even if there are complicating factors such as a CVA.
Symptoms of posttraumatic stress, depression, and unresolved grief can appear in children and adolescents following the witnessing or experiencing of a traumatic event and respond with intense fear, helplessness, or horror. Those who lose a loved one in a traumatic manner can develop childhood traumatic grief (CTG), where typical grieving is hindered by trauma symptoms, causing significant impairment in daily functioning, relationships, and academic pursuits. The following is a case study describing a trauma-focused cognitive behavioral approach to treat posttraumatic stress disorder and CTG in a 16-year-old driver of a motor vehicle accident in which his peer was killed. A graduate student clinician provided treatment under supervision within the context of a school mental health program. The results of the intervention were associated with significant reductions in symptoms and impairments in daily living. The implications of these data and recommendations for clinicians treating CTG are provided.
Chronic diseases such as type 2 diabetes mellitus (T2DM) are increasingly common and costly, imparting debilitating economic and health effects. This case presents the use of an individualized behavioral intervention for diabetes management in a 61-year-old African American woman with T2DM. The intervention was delivered over five home-based treatment sessions and two follow-up probes that focused on nutrition. At the end of treatment, the participant exhibited improved nutrition and dietary habits (i.e., increased intake of fruits and vegetables; eating more, smaller meals throughout the day), which maintained through follow-up. In addition, she demonstrated generalization of treatment effects, as evidenced by the application of treatment strategies to other areas of her health (i.e., exercise and blood glucose testing). This case study highlights how psychological treatment emphasizing behavioral techniques can be effectively applied to manage medical conditions and mitigate future complications and comorbidities.
The clinical research and treatment options for sexual paraphilias are scant and have generally been limited to psychodynamic and early behavioral approaches. This article highlights the application of two existing evidence-based modern behavioral interventions, specifically behavioral activation and sensate focused therapy, to treat foot fetishism/sexual impulses and co-occurring mood/anxiety symptoms in a 57-year-old male Vietnam War veteran. This brief 6-week treatment addressed the patient’s complicating psychosocial factors and medical conditions, and focused on targeting behavioral avoidance symptoms associated with fetishism and depression (e.g., increasing socially and sexually appropriate and positive reinforcing behaviors in his environment). The patient no longer met diagnostic criteria for fetishism and endorsed significant reductions in depressed mood, anxiety, and stress at post-treatment and 1-month follow-up. This case illustrated how current behavioral treatments may be used to successfully treat patients with rare symptom presentations who may otherwise be neglected within a medical system.
This case study discusses the treatment of an emergency responder to the 2007 shooting on Virginia Tech’s campus where 33 students and faculty members were killed. After a thorough assessment, prolonged exposure (PE) was used to treat the emergency worker, referred to as Jack, for posttraumatic stress disorder (PTSD). Assessment measures administered at the conclusion of treatment, 1 month post-treatment, and 6 months post-treatment suggest that the treatment gains were maintained following the culmination of treatment. The primary aim of this article is to provide support for the effectiveness of PE among emergency responders who develop PTSD. In addition, this case presentation is particularly important given the prevalence of mass shootings in the United States. Several complicating factors, including a delay in treatment seeking, arose over the course of treatment and are discussed.
The United States is facing the challenge of a growing number of migrating unaccompanied minors. These children have often witnessed and experienced severe traumatic events before and during their journey to a foreign country. In addition, they face cultural shock, loss of social network, and language barriers while navigating complicated asylum procedures and the possibility of being returned back to their country of origin. As a result, they present with several emotional and behavioral difficulties, but also profound amounts of resiliency. This case study presents the treatment of a young unaccompanied minor experiencing severe post-traumatic stress disorder. A relational psychodynamic approach, integrated with trauma focused intervention, is illustrated.
This case study examines how parents can be incorporated into all aspects of cognitive-behavioral therapy (CBT) for child anxiety problems. This is an important issue, because although there are strong theoretical and empirical reasons for incorporating parents into treatment, evidence from randomized controlled trials has so far been inconclusive about whether outcomes are improved by involving parents. This case study describes the clinical benefits of a balanced focus on parent and child factors for "Laura," an 8-year-old girl experiencing a range of fears and worries, including refusing to attend school. Treatment consisted of seven sessions of CBT, which targeted parent and child factors hypothesized to be critical to the development and maintenance of Laura’s anxiety problems. The clinician’s decision making and reasoning in carefully selecting CBT interventions to specifically address the presenting problems are illustrated. Laura showed marked reductions in avoidance behaviors and fears and returned full-time to school.
The treatment of blood-injection-injury (BII) phobia has a unique treatment component as compared with other types of specific phobias. In particular, many patients with a BII phobia distinctively experience an increased susceptibility to fainting when exposed to feared medical-related stimuli due to a diphasic physiological response. Moreover, effective treatment protocols must not only include therapeutic techniques to ameliorate the patient’s fear response but also teach strategies that will allow the patient to remain conscious during exposure to feared stimuli. The current case study describes a manualized, cognitive behavioral therapy that utilized applied muscle tension techniques to comprehensively address the multifaceted components of an adult male’s BII phobia. Treatment included a combination of psychoeducation and cognitive restructuring that provided the patient with an empirically based understanding of BII phobia, practiced using applied muscle tension techniques to better manage his physiological processes during exposure followed by the utilization of in vivo graduated exposure to reduce distress and avoidance of feared stimuli. After completing nine sessions, the patient demonstrated considerable improvement as evidenced by reductions in anxiety and the willful seeking of medical care following treatment. Further implications and future directions for research are discussed.
We report the case of an 11-year-old boy with autism who displayed aggressive behavior and required aggression-contingent physical restraint (protective holding) to protect peers and teachers from injury. During a baseline phase, teachers implemented the boy’s behavior support plan and applied protective holding according to a behavior-contingent release (BCR) criterion in which they maintained physical contact with him until he was "calm" for a minimum of 30 consecutive seconds. In the intervention phase, baseline procedures remained in effect, but the teachers terminated protective holding with the boy according to a fixed-time release (FTR) criterion that was independent of his behavior during protective holding and faded (decreased) systematically over time. In contrast to BCR, FTR fading was associated with less exposure to and fewer applications of protective holding. Post-intervention and follow-up results revealed that protective holding was no longer required. We discuss the clinical implications of these findings.
This case study presents the treatment of a 23-year-old single White male with a specific phobia of swallowing and choking on pills. He presented for treatment as part of a larger treatment study for specific phobia and met criteria for a specific phobia, other type (swallowing pills), and social phobia. Treatment of the specific phobia involved One-Session Treatment and was conducted per Zlomke and Davis and Davis, Ollendick, and Öst. A posttreatment assessment 3 weeks after treatment and an 8-week follow-up assessment revealed significant improvements. At both assessments following treatment, clinician severity ratings on the Anxiety Disorders Inverview Schedule—Client (ADIS-IV) decreased, indicating no significant impairment, and the ADIS-IVs at those time periods indicated he no longer met criteria for a specific phobia. Improvements were also seen in the client’s self-reported fear, on his ratings of catastrophic cognitions, on a behavioral avoidance task, and in the comorbid social phobia symptoms.
Although reality therapy has been effective in reducing symptoms of depression in adults, there is little research to support the use of reality therapy with deaf adults. This article demonstrates the use of reality therapy in reducing symptoms of depression in a deaf adult. Cultural competence is an important factor in the psychological treatment of individuals. It is important for clinicians to identify the cultural components that can play a part in the client’s identity and treatment. The objective of this study is to highlight the importance of cultural competence and the use of reality therapy to help in meeting therapeutic goals.
Mindfulness-based therapy (MBT) has shown promise in reducing depression and psychological distress among individuals presenting with various medical and psychiatric problems. This case study examined the implementation of MBT with an undergraduate student with recurrent major depression and generalized anxiety disorder. A novel four-session MBT protocol was utilized and the patient demonstrated significant decreases in depressive and anxiety symptoms and an overall increase in quality of life at the posttreatment assessment. Treatment gains were maintained at the 1-month follow-up assessment. Consistent with previous treatment outcome studies examining the efficacy of comprehensive MBT interventions, results indicate that an abbreviated MBT protocol may be effective in treating depression and anxiety in younger adults.
Elder abuse is a pervasive problem that can have lasting emotional and physical consequences, increasing its victims’ risk of mortality. Healthcare providers are frequently involved in the detection and intervention of elder abuse. Because of the complexity of these cases, applying treatment interventions within an interdisciplinary care team has been recommended to ensure older adults’ safety and welfare. Psychologists in particular are frequently relied upon in these situations because of their expertise in cognitive, psychiatric, and capacity assessment, as well as their ability to intervene in a variety of difficult situations. The following is a report examining the case of Mr. B, who was a victim of elder abuse involving financial exploitation and undue influence. Assessment and treatment interventions were used within the context of an interdisciplinary care team, using a bio-psychosocial approach. A decision-tree model describing the steps to take in assessing and treating financial elder abuse is proposed.
The present study examines the therapy of an individual diagnosed with generalized anxiety disorder, two situation type specific phobias, and nicotine dependence. Treatment consisted of psychodynamic psychotherapy with adjunctive hypnosis. Client’s symptoms were tracked using daily, self-report measures over the 6-month treatment period. The simulation modeling approach for time-series was used to assess the phase change from baseline to treatment. Tracked symptoms included generalized anxiety, worry associated with specific phobias, phobic avoidance, number of cigarettes smoked daily, and nicotine craving intensity. All symptoms decreased significantly over the course of treatment. Utility of an ideographic and also quantified research methodology for treatment outcome studies are discussed.
This case study reports on the use of a developmentally sensitive behavioral treatment program for a 4-year-old Korean girl diagnosed with selective mutism. Multi-method assessment, consisting of parent and teacher reports, as well as school and home-video observation, confirmed the diagnosis. Behavioral therapy was administered with an emphasis on behavioral reinforcement strategies that were adapted for the child’s developmental level. After 17 sessions, the child evidenced a notable reduction in selective mutism symptoms, evidenced by clinician and school observation. Furthermore, she indicated a decrease in symptoms of withdrawal based on teacher report. This case study demonstrates how behavioral treatment strategies emphasizing behavioral reinforcement techniques can be applied in developmentally appropriate ways to treat young, bilingual children with selective mutism.