Clinical Case Studies RSS feed -- OnlineFirst Articles

Progress Toward a Resurgence and Remodeling of Psychotherapy for Schizophrenia: Editors' Introduction to Special Issue of Clinical Case Studies

Silverstein, S. M., Lysaker, P. H. — Tue, 24 Nov 2009 03:38:34 PST

This special issue of Clinical Case Studies focuses on recent developments in the psychotherapy of schizophrenia.Approaches such as these are needed to address the multiple rate-limiting factors for psychotherapy outcome in this population, such as poor insight, comorbid disorders, low motivation, cognitive impairments, and self and interpersonal disturbances. In this introductory article, each of the case studies is briefly reviewed, with the goals of: (a) noting how each therapeutic approach fills a gap in current practice, and (b) placing the focus of treatment within a larger context of relevant research on schizophrenia. Concluding comments note the implications of these multiple therapeutic developments for future psychological treatment of schizophrenia.

Psychotherapy for Schizophrenia in an ACT Team Context

Smith, S. M., Yanos, P. T. — Tue, 24 Nov 2009 03:38:33 PST

Cognitive-behavioral therapy (CBT) and assertive community treatment (ACT) are two evidence-based approaches to the treatment of schizophrenia; nevertheless, the two approaches are rarely combined. In the present case study, we discuss the treatment of a man diagnosed with schizophrenia with severe social anxiety. CBT approaches were used and treatment was conducted within the context of ACT services.CBT and ACT were found to be complementary, and the combination of approaches was found to be effective helping to reduce the client’s social anxiety. Implications for the treatment of schizophrenia are discussed.

Addressing Metacognitive Capacity in the Psychotherapy for Schizophrenia: A Case Study

Buck, K. D., Lysaker, P. H. — Tue, 24 Nov 2009 03:38:33 PST

Deficits in metacognition, that is, in the ability to think about one’s own thinking and the thinking of others, have been identified as a significant barrier to recovery from schizophrenia. While this has raised the possibility that individual psychotherapy might be focused to help persons with schizophrenia improve their capacity for metacognition, little has been written about what that might entail. To explore this issue, a case study is presented in which ongoing assessments of metacognition were used to guide the selection of interventions. Interventions were chosen in particular to match the client’s capacity for metacognition at that time and were conceptualized as offering maximal opportunities for the practice and development of metacognitive capacity. Improvements in function and the development of the ability to perform increasingly complex acts of metacognition are reported over the course of approximately 1.5 years of therapy and implications for research and theory are discussed.

Concurrent Treatment of Substance Abuse, Child Neglect, Bipolar Disorder, Post-Traumatic Stress Disorder, and Domestic Violence: A Case Examination Involving Family Behavior Therapy

Tue, 24 Nov 2009 03:38:34 PST

High rates of co-occurrence between substance abuse and child neglect have been well-documented and especially difficult to treat. As a first step in developing a comprehensive evidence-based treatment for use in this population, the present case examination underscores Family Behavior Therapy (FBT) in the treatment of a mother who evidenced Substance Dependence, child neglect, Post-Traumatic Stress Disorder, Bipolar I Disorder, and domestic violence. Utilizing psychometrically validated self-report inventories and objective urinalysis, treatment was found to result in the cessation of substance use, lower risk of child maltreatment, improved parenting attitudes and practices, and reduced instances of violence in the home. The importance of utilizing validity scales in the assessment of referrals from child welfare settings is discussed, and future directions are reported in light of the results.

Psychotherapy of Schizophrenia: A Brief History and the Potential to Promote Recovery

Lysaker, P. H., Silverstein, S. M. — Tue, 24 Nov 2009 03:38:33 PST

With growing awareness of the likelihood of recovery from schizophrenia, interest has arisen about the potential role of psychotherapy within emerging treatment regimens. Could psychotherapy uniquely promote recovery by addressing symptoms, the achievement of psychosocial milestones, and/or helping to enhance the extent to which persons diagnosed with schizophrenia experience themselves as meaningful agents in the world? As an introduction to a set of case studies of how psychotherapy can promote recovery this article briefly reviews the history of the psychotherapy of schizophrenia. In particular the appearance and course of psychoanalytically oriented treatments, as well as cognitively and interpersonally based treatments are detailed. Evidence supporting these approaches and remaining questions for research are discussed.

Medusa's Stare: A Case Study of Working With Self-Disturbance in the Early Phase of Schizophrenia

Nelson, B., Sass, L. A. — Tue, 24 Nov 2009 03:38:33 PST

The present therapeutic case study demonstrates how concepts from phenomenological psychiatry can be applied to treatment of the early phase of schizophrenia. The case described here is of a 22-year-old man seen at a youth mental health service who experienced a catatonic episode with residual cognitive symptoms. The notion of a disturbed basic sense of self—based on the ipseity-hyperreflexivity model and the concept of ontological anxiety—formed the basis of the clinical formulation and treatment. These concepts highlight the patient’s vulnerabilities and difficulties in interpersonal contact. In addition they help to clarify potential dangers inherent in "objectifying" the patient, in stimulating excessive self-reflection, and in encouraging interpersonal engagement that is overly intense. Alternative strategies guided by a phenomenological appreciation of the centrality of a disturbed basic sense of self (disturbed ipseity) are described. These include certain forms of empathic understanding, including use of phenomenological concepts to help the patient comprehend their difficulties, encouraging a "second person" perspective, prominent use of the therapeutic relationship, and strategies that engender a form of immersion or absorption in present activity.

Advances in Cognitive Therapy for Schizophrenia: Empowerment and Recovery in the Absence of Insight

Perivoliotis, D., Grant, P. M., Beck, A. T. — Tue, 24 Nov 2009 03:38:32 PST

Lack of awareness of a mental disorder is a prevalent feature of schizophrenia and is associated with poor outcome. Cognitive therapy (CT) is a promising adjunctive treatment for schizophrenia but is believed to be less efficacious for patients with poor insight. This article describes a goal-oriented CT approach that was innovated to circumvent limited insight in a young woman with severe paranoid delusions and auditory hallucinations. The treatment facilitated recovery by targeting avoidance, inactivity, and social withdrawal, and by promoting detachment from psychotic experiences without directly challenging delusional beliefs. The case study demonstrates the involvement of family in CT and the use of behavioral exercises to modify dysfunctional beliefs and behaviors. Results are consistent with recently advanced cognitive conceptualizations of schizophrenia and suggest that when appropriately tailored and focused on functional goals, CT can promote recovery in the absence of insight.

A Novel Approach to Treating Anxiety and Enhancing Executive Skills in an Older Adult With Parkinson's Disease

Tue, 24 Nov 2009 03:38:34 PST

Scientific interest in the nonmotoric symptoms of Parkinson’s disease (PD) has increased dramatically, and psychiatric symptoms (e.g.,cognitive impairment,anxiety,and mood disorders) are now considered prime targets for treatment optimization. Psychiatric complications in PD are quite common, affecting as many as 60% to 80% of patients.This study describes the case of a 74-year-old male with PD who presented with complaints of anxiety and trouble with memory and attention. A combined cognitive behavior therapy (CBT) and cognitive enhancement intervention was delivered in ten 90-to-120 minute sessions.The patient showed a reduction in anxiety symptoms that was of sufficient magnitude to meet criteria for "responder" status.His cognitive skills were mostly unchanged, despite the rigorous rehabilitation practice. Implications for treatment and strategies for enhancing therapeutic benefits are discussed.

Cognitive Behavior Therapy and Worry Reduction in an Outpatient With Generalized Anxiety Disorder

Khodarahimi, S., Pole, N. — Wed, 28 Oct 2009 04:23:20 PDT

This article describes the treatment of a 27-year-old female with a particularly challenging manifestation of generalized anxiety disorder (GAD) with prominent worry. A manualized cognitive–behavioral therapy (CBT) protocol, including problem-solving training, cognitive restructuring, and relaxation training techniques, was tailored to the patient’s presenting profile. Several self-report measures administered during the pretreatment, post-treatment, and follow-up periods, including: the Penn State Worry Questionnaire (PSWQ), the Why Worry-II (WW-II), the Ahwaz Worry Inventory (AWI), and the Intolerance of Uncertainty Scale (IUS), indicated significant worry reduction following treatment. Many difficulties were encountered, most notably designing and monitoring homework. Treatment implications are discussed.

From Dangerous to Discharged: An Application of Social-Learning-Based Procedures in an Acute Hospital Setting

Springer, J. R., Sloan, P. A., Benge, J. F., Spence, M., Carlo, I., Teng, E. J. — Wed, 28 Oct 2009 04:23:20 PDT

Psychiatric inpatients who demonstrate persistent aggressive behavior present unique treatment planning and placement challenges. This article presents the case of a severely Veteran who demonstrated high levels of aggressive behavior as well as persistent adaptive behavior deficits. A comprehensive Treatment Recovery and Rehabilitation Plan (TRRP) based on Social-Learning Program procedures resulted in rapid improvements in recovery-related outcomes and discharge within 31 days of TRRP initiation. This intervention significantly reduced maladaptive behavior and increased treatment participation. These improvements were unrelated to pharmacotherapy changes during the hospitalization. Following discharge, a re-emergence of problematic behaviors in a community placement resulted in a more restrictive rehospitalization. The absence of TRRP implementation at this placement likely contributed to the re-emergence of problem behavior. This case illustrates the importance of implementing evidence-based psychosocial interventions in acute settings, engaging in recovery-oriented treatment planning, and maintaining continuity of care across settings.

Cognitive Behavior Therapy for Sexually Addictive Behavior

Shepherd, L. — Wed, 28 Oct 2009 04:23:20 PDT

This case details the use of cognitive behavior therapy in treating a 41-year-old gay man’s sexually addictive behavior. At assessment, he perceived his sexual behavior to be out of his control and it was particularly interfering with his work life. Motivational interviewing was combined with a number of cognitive behavioral techniques, including a behavior change program, distraction, enhancing metacognitive awareness, and cognitive restructuring, over the course of six therapy sessions. Using self-report, the intervention led to a significant reduction in sexual behavior. Frequency of sexual partners and the amount of time spent online during working hours reduced. The case highlights effectiveness of cognitive behavior therapy and motivational interviewing in reducing sexually addictive behavior and installing a sense of control in patients.

"Don't Kick Me Out!": Day Treatment for Two Preschool Children With Severe Behavior Problems

Burke, R. V., Kuhn, B. R., Peterson, J. L., Peterson, R. W., Badura Brack, A. S. — Wed, 14 Oct 2009 04:16:49 PDT

Parents of young children with severe emotional and behavior problems have few services from which to choose if their child is expelled from preschool for aggressive and disruptive behavior. Two case studies provide an overview of a multicomponent, intensive, day-treatment program for children with moderate to severe behavior disorders. Proximal and distal program goals are to eliminate presenting problem behaviors and increase social competencies and to reintegrate children back to their school, preschool, or daycare, respectively. The cases presented in this study provide preliminary evidence that day treatment can be a viable option for young children with disruptive behavior disorders.

Intimate Partner Abuse: A Case Study Involving a Father and a Son

Aymer, S. R. — Wed, 14 Oct 2009 04:16:48 PDT

Intimate partner abuse cases usually center on providing services to mothers and their children. This article discusses a paradigm shift—a father–son dyad is presented—illustrating how intimate partner abuse affects their relationship. Attachment, social learning, fatherhood, masculinity, and complex trauma theories are used to ground the case. Boss’s paradigm of ambiguous loss is used to conceptualize, assess, and describe the course of treatment. Finally, recommendations to clinicians are discussed.