Clinical Case Studies recent issues

Skills-Based Group Intervention for Adolescent Girls With Inflammatory Bowel Disease

Hayutin, L. G., Blount, R. L., Lewis, J. D., Simons, L. E., McCormick, M. L. — Wed, 23 Sep 2009 23:53:13 PDT

In this study we describe the responses of six adolescent girls with inflammatory bowel disease and their parents to a 10-session, manualized intervention program focusing on decreasing pain and functional disability in adolescents with a chronic illness, and increasing coping and sense of competency for their parents. Measures of adolescent physical symptoms and parenting sense of competence and coping were collected at pretreatment, post-treatment, and 6-month follow-up. Improvements were observed post-treatment and at 6 month follow-up on measures of adolescents’ pain and functional disability, as well as parents’ sense of competency and use of adaptive coping strategies.The potential effectiveness of this type of program and implications for its use are discussed.

Multisystemic Therapy Applied to the Assessment and Treatment of Poorly Controlled Type-1 Diabetes: A Case Study in the U.K. National Health Service

Martin, C., Southall, A., Liveley, K., Shea, E., Whitehead, K. — Wed, 23 Sep 2009 23:53:13 PDT

The objective of this article is to describe the case of a twelve-year-old girl with Type-1 Diabetes, who had a history of hospitalisation due to Diabetes Ketoacidosis (DKA) and had been placed into the child protection register. The report advocates an Understanding of the Social Ecological Model (Bronfenbrenner, 1976) in relation to assessing poor metabolic control, and examines the use of Multisystemic Therapy (MST) in treatment adherence. The assessment explores the beliefs within the child’s systems and subsystems. Formulating from a Systemic Perspective allowed for integrated Cognitive Behavioural Therapy, Family Therapy and Systems Oriented intervention applied to the Microsystems’ beliefs. After treatment and at follow-up the child was removed from the Child Protection register and has remained to date without admission to hospital experiencing DKA. MST has the possibility of offering a new perspective for treatment in complex cases of children with diabetes and severe treatment adherence problems.

Culturally Sensitive Treatment of Anger in African American Women: A Single Case Study

Gonzalez-Prendes, A. A., Thomas, S. A. — Wed, 23 Sep 2009 23:53:13 PDT

Culturally sensitive clinical practice challenges practitioners to recognize the cultural significance and importance of clients’ behaviors and belief systems.This article reports a case study of the treatment of anger in an African American woman. Presented within a framework of cognitive-behavioral theory, the case illuminates three important issues that influence experience and expression of anger in African American women: the influence of gender role socialization on the mode of anger expression; the experience of powerlessness, rooted in historical and contemporary discriminatory and oppressive realities; and culture-related messages that create unrealistic expectations of strength.The article addresses conceptualization, assessment, treatment processes,and clinical strategies,as well as limitations of a single case study, implications for practice and recommendations for future research.

Treatment of a Depressed Breast Cancer Patient With Problem-Solving Therapy

Carvalho, J. P., Hopko, D. R. — Wed, 22 Jul 2009 02:46:17 PDT

Problem-solving therapy (PST) has emerged as a promising treatment for major depressive disorder (MDD). The treatment, which is brief and easily accessible to a variety of health practitioners, has often been implemented within primary care settings. Building on this research, this case study highlights utilization of problem-solving therapy with a breast cancer patient diagnosed with recurrent major depression, applied within the context of a medical center oncology clinic. Following an 8-session PST protocol, the patient demonstrated notable decreases in self-reported depression and anxiety symptoms and an overall increase in quality of life and medical functioning. Consistent with an accumulating literature, these data support PST as an effective and parsimonious intervention for individuals with depression and concurrent medical problems such as breast cancer.

Implications of Emotional Eating Beliefs and Reactance to Dietary Advice for the Treatment of Emotional Eating and Outcome Following Roux-en-Y Gastric Bypass: A Case Report

Chesler, B. E., Harris, B. G., Oestreicher, P. H. — Wed, 22 Jul 2009 02:46:17 PDT

This case describes cognitive—behavioral treatment for emotional eating, preceding and following Roux-en-Y gastric bypass, which is associated with 84.52% excess BMI (body mass index) loss 53 months after surgery. It explores the relevance of emotional eating beliefs (EEB; that is, equating food with both alleviation of negative feelings and friendship) and reactance to dietary advice (RDA; that is, rebelling against prescribed nutrition) for the deliberate use of food to feel both better and befriended. EEB and RDA motivate and justify, respectively, the conscious consumption of rich or "forbidden" foods. Simultaneous treatment of EEB and RDA is associated with the utilization of rational thinking and problem solving to cope with emotional discomfort. Remediation of equations of food with friendship engenders amelioration of distress through spousal support. Unrecognized emotional distress fueling reflexive eating and accompanying external eating are found. External eating is decreased coincident with therapy for emotional eating. Implications are discussed.

Combining Acceptance and Commitment Therapy and Cognitive Behavioral Therapy for the Treatment of Chronic Pain in Older Adults

Lunde, L.-H., Nordhus, I. H. — Wed, 22 Jul 2009 02:46:17 PDT

The article discusses a combination of cognitive-behavioral therapy (CBT) for chronic pain and acceptance and commitment therapy (ACT) that was applied to an older adult. Findings reveal that a brief intervention of 8 weeks was effective in producing a clinically significant change in pain experience, as well as an increase in sleep quality/sleep maintenance and acceptance of pain. It is suggested that a central ACT component such as mindfulness skills as well as the focus on values may contribute to efficacy of cognitive behavioral treatment for chronic pain.

Effects of Nonverbal Social Disapproval on Attention-Maintained Spitting and Disruptive Vocalizing in a Child With Autism

Kozlowski, A., Wood, L., Gilligan, K., Luiselli, J. K. — Wed, 22 Jul 2009 02:46:17 PDT

This study addressed attention-maintained problem behaviors (spitting and disruptive vocalizing) of a child with autism. The intervention procedures consisted of service providers cleaning up the presence of saliva and demonstrating a "quiet" cue when the child spit and vocalized respectively. In two single-case reversal designs, the procedures reduced both behaviors to low frequency. Factors responsible for intervention success are discussed.

Treatment of Chronic Skin-Picking in an Adolescent With Asperger Syndrome and Borderline Intellectual Disability

Lang, R., Didden, R., Sigafoos, J., Rispoli, M., Regester, A., Lancioni, G. E. — Wed, 22 Jul 2009 02:46:17 PDT

We present the case of a 17-year-old girl with Asperger syndrome and borderline intellectual disability with a 5-year history of chronic skin-picking. Our intervention approach included an initial functional assessment to identify variables maintaining skin-picking, followed by evaluation of a behavioral treatment package. Results of the functional assessment suggested that skin-picking was maintained by automatic reinforcement in the form of tactile and visual stimulation. The intervention, consisting of an antecedent control procedure (covering areas with bandages) and differential reinforcement, was evaluated in an ABAC single-case experimental design. The number of open sores decreased from an average of 37 in baseline to zero during intervention. No new sores were found 4 months following intervention. These results suggest that the treatment package was effective in reducing skin-picking and that the treatment effects were maintained, but it was not clear if both treatment components were necessary and/or sufficient for behavior change.

The Personality Assessment Inventory in the Evaluation of Multiple Channel Exposure Therapy

Petrac, D. C., Bedwell, J. S. — Wed, 22 Jul 2009 02:46:17 PDT

The National Comorbidity Survey (NCS) determined that the comorbidity rate of posttraumatic stress disorder (PTSD) with panic disorder is 7.3% for males and 12.6% for females. A 21-year-old female's presenting symptoms corresponded to this dual diagnosis, with the addition of comorbid major depressive disorder. The Personality Assessment Inventory (PAI) was used as part of an initial comprehensive assessment battery. Treatment was provided over a period of 6 months, and multiple channel exposure therapy (MCET) was chosen as the primary treatment, as it has been shown to be a promising treatment for the comorbid presentation of PTSD with panic disorder. Upon completion of the MCET, the PAI was readministered as a posttreatment evaluation. The posttreatment PAI results indicated clinical improvement across all indices that initially suggested clinical problems. Results of this case study suggest that the PAI is sensitive to treatment gains from the MCET for the comorbid conditions of PTSD, panic disorder, and major depressive disorder.

Unresolved PTSD in a Hispanic Woman Presenting With Test Anxiety

Henslee, A. M., Schumacher, J. A., Holloman, G., Coffey, S. F. — Wed, 22 Jul 2009 02:46:17 PDT

This article illustrates the unique symptom presentation and outpatient treatment of posttraumatic stress disorder (PTSD) in a Hispanic female. The patient was referred to therapy to address problems with concentration and difficulties related to test-taking. A motivational interviewing-based assessment was conducted and the case was conceptualized in a cognitive— behavioral framework. After resolution of test-taking anxiety, additional anxiety symptoms emerged, including subclinical panic disorder and evidence of unresolved PTSD. Prolonged Exposure was initiated to successfully treat residual trauma-related symptoms. Recommendations for assessment and treatment of individuals with a trauma history are provided, with an emphasis on the need for sensitivity to cultural issues.

Habit Reversal Treatment of Repetitive Hand Writing in a 7-Year-Old Child with a Learning Disability

Shumaker, D. M. — Thu, 14 May 2009 23:07:57 PDT

Habit reversal (HR) is a cognitive—behavioral treatment for tic disorders, Tourette syndrome, stereotypic movements, and habit disorders. This case study utilizes aspects of habit reversal, including awareness training, self-monitoring, and competing response training, as an intervention for obsessive—compulsive repetitive air handwriting in a 7-year-old girl with a significant learning disability. Therapy is provided on an outpatient basis in a private practice setting. Analysis of in-home, at-school, and in-session data collected by the parents, teacher, and therapist show decreased frequency in repetitive handwriting. Supplemental and cojoint administration of antianxiety medication extinguishes all obsessive handwriting within a 6-month period. These results support previous research demonstrating the efficacy of cojoint cognitive—behavioral and medication treatment of acute obsessive—compulsive symptomatology in children.

Evidence-Based ADHD Treatment with a Spanish-Speaking Latino Family

Gerdes, A. C., Schneider, B. W. — Thu, 14 May 2009 23:07:57 PDT

Though data support effective treatments for attention-deficit hyperactivity disorder (ADHD), little research examining these interventions with ethnic minority families exists. Thus, the current case study focuses on a Spanish-speaking, Latino family assessed and treated in a university-based ADHD clinic implementing evidence-based treatment. In addition to discussing the course of treatment, this case study highlights some of the challenges faced when treating ethnic minority families and identifies several lines of research needed to fully explore ethnicity and treatment outcomes in child psychotherapy.

Initial Treatment Success Followed By Failure: How Do We Deal With Toxic Core Beliefs in the Context of Comorbid Major Depression With Psychotic Features, Social Phobia, and Axis II Pathology?

Prisciandaro, J. J., Roberts, J. E. — Thu, 14 May 2009 23:07:57 PDT

This article presents a diagnostically complicated case involving comorbid major depressive disorder with psychotic features, social phobia and personality pathology (including avoidant, paranoid, and obsessive compulsive traits). "Mr. X" was a 45-year-old single White male who was unemployed and living with his parents at the time of treatment. He presented with severe anxiety (Beck Anxiety Inventory = 43) and depression (Beck Depression Inventory = 41) as well as active psychotic symptoms (e.g., self-depreciating auditory hallucinations). Although a cognitive case formulation and treatment plan led to initial success in terms of improvements in symptomatology and functional impairment, we speculate that failure to adequately address core toxic beliefs (e.g., "I am inadequate") ultimately contributed to a precipitous return of symptomatology, followed by a suicide attempt and premature treatment termination. We discuss the challenges of working within a cognitive framework with this client and suggest alternative approaches that might have proven more successful.

"Giving It Space": A Case Study Examining Acceptance and Commitment Therapy for Health Anxiety in an Older Male Previously Exposed to Nuclear Testing

Jourdain, R. L., Dulin, P. L. — Thu, 14 May 2009 23:07:57 PDT

Most psychotherapeutic approaches have been developed for problems that have an "irrational" or "pathological" foundation. These approaches often fit poorly with psychological distress that stems from cognitions that are based in reality and may need to be accepted rather than changed. Acceptance and Commitment Therapy (ACT) is currently being applied to a number of conditions, but may be particularly useful in situations where cognitive change is not warranted. This study examined ACT with an older male of Maori descent experiencing high levels of health anxiety resulting from prior nuclear testing exposure while in the military. Results of self-report measures administered at baseline, during treatment, post-treatment, and at 6-week follow-up indicated clinically significant reductions in health anxiety, experiential avoidance, and overall distress. This case study has implications for the utility of ACT with individuals who are distressed about the real possibility that their health has been negatively affected by toxic exposure.

The Six-Point Dial of Treatment: A Useful Framework for Novice Therapists

Witte, T. K., Gordon, K. H., Joiner, T. E. — Thu, 14 May 2009 23:07:57 PDT

The 6-point dial of treatment described in this case report is developed to guide graduate student psychological trainees through treatment and includes the following components: assessment of dangerousness, diagnosis, diagnosis-based treatment, ongoing evaluation of treatment response, obstacles to treatment, and motivation. The article describes the dial of treatment and present a case study of a client with paranoid schizophrenia (John) who presented at a graduate student training clinic to illustrate how this framework can be successfully applied. John exhibits marked improvement, based on both objective measures and clinician judgment of global functioning.

Enhancing the Therapy Relationship in Acceptance and Commitment Therapy for Psychotic Symptoms

Baruch, D. E., Kanter, J. W., Busch, A. M., Juskiewicz, K. L. — Thu, 14 May 2009 23:07:57 PDT

The article demonstrates how acceptance and commitment therapy (ACT) may effectively alter the function of positive psychotic symptoms and how functional analytic psychotherapy (FAP) may provide a complimentary framework for interpersonal change. ACT differs with many psychosis approaches in that it does not attempt to reduce psychotic symptoms; instead, it aims to increase psychological flexibility (e.g., acceptance) in the presence of psychotic symptoms while actively pursuing valued living. The study involves, John, a 21-year-old college student, who presented with depressive symptoms, delusional and brief visual hallucinatory episodes, and severe social isolation. ACT interventions emphasize acceptance of, and mindful reactions to, psychotic symptoms while pursuing valued life goals. As John's main goal of treatment was to develop more intimate interpersonal relationships, FAP techniques were introduced as behaviors that seemed to be distancing him from peers manifested themselves in session. The benefits and challenges of integrating ACT and FAP are discussed.

The Use of Emotive Imagery and Behavioral Techniques for a 10-Year-Old Boy's Nocturnal Fear of Ghosts and Zombies

Shepherd, L., Kuczynski, A. — Sun, 29 Mar 2009 13:00:40 PDT

This case describes the use of emotive imagery and behavioral techniques in treating a 10-year-old boy's nocturnal fear of ghosts and zombies. His anxiety had led to nightmares and avoidance of sleeping in his bedroom. To a significant degree, the intervention was led by the child. With the therapist's support, the child developed and deployed a number of imaginary characters during and between sessions to reduce his sense of threat about ghosts and zombies. Relaxation, boundary setting, and an incentive program were also implemented to target residual avoidant behavior. Self-reported anxiety measured by a diary and on the Spence Children's Anxiety Scale reduced during the course of treatment. Furthermore, the frequency of his nightmares decreased and the number of nights that he spent in his bedroom increased. The case highlights the effectiveness of emotive imagery in treating anxiety surrounding imaginary creatures in children. It also suggests that behavioral techniques may also be required to effectively promote behavior change.

Intensive Cognitive-Behavioral Therapy for Adolescents With Body Dysmorphic Disorder

Aldea, M. A., Storch, E. A., Geffken, G. R., Murphy, T. K. — Sun, 29 Mar 2009 13:00:40 PDT

Cognitive-behavioral therapy (CBT) with exposure and response prevention has documented efficacy in adults with body dysmorphic disorder (BDD) but has yet to be systematically studied in youth. With this in mind, the authors report on the case of "Amanda," a 16-year-old female with significantly impairing BDD symptoms. Following 17 sessions of intensive family-based CBT, Amanda exhibited marked improvement in her BDD symptoms as illustrated by a decrease in her score on the Body Dysmorphic Disorder Modification of the Yale-Brown Obsessive Compulsive Scale from 27 at baseline to 10 at posttreatment. Therapeutic gains were maintained at a 3-month follow-up. This case study provides preliminary support for the use of intensive family-based CBT for adolescent BDD.

Integrating Functional Analytic Psychotherapy and Behavioral Activation for the Treatment of Relationship Distress

Sun, 29 Mar 2009 13:00:40 PDT

The following case study demonstrates the potential for an integrated behavioral treatment to improve interpersonal functioning, specifically within a romantic relationship. This integrated treatment utilizes strategies from both Functional Analytic Psychotherapy (FAP) and Behavioral Activation (BA), and thus is termed FAP-Enhanced BA (FEBA). This case study represents an initial attempt to apply FEBA to a 22-year-old female undergraduate, Megan, presenting with relationship distress. Megan and her partner both completed a pretreatment and posttreatment assessment that included self-report questionnaires in addition to a conflict-interaction task that was later coded for the presence of specific emotions. After the pretreatment assessment, Megan participated in 8 sessions of FEBA. Session-by-session descriptions and data will be presented, as well as data from the pretreatment and posttreatment assessments.

Exposure-Based Treatment for a Child With Stabbing Obsessions

Cassano, M. C., Nangle, D. W., O'Grady, A. C. — Sun, 29 Mar 2009 13:00:41 PDT

This article describes the course of treatment for a 10-year-old boy presenting with a particularly challenging manifestation of pediatric Obsessive-Compulsive Disorder (OCD). Guided by a manualized cognitive-behavioral protocol, cognitive and exposure-based techniques were tailored to "match" the clients' interests and content of symptoms (stabbing self and mother). Several sources of information (continuous self-monitoring, rating scales, self-and parent-report) indicated significant treatment gains that were sustained 3 months posttreatment and offer possible insight as to the relative efficacy of treatment components. Several challenges were encountered, most notably designing and supervising exposure exercises involving sharp objects. Several treatment implications are discussed including tailoring manualized treatments, managed care issues, and recommendations for students, clinicians, and supervisors.