Clinical Case Studies, Ahead of Print.
Functional neurological symptom disorder (FND) is associated with complex specialist investigations and poor prognosis. The theoretical understanding of FND posits that functional symptoms are predisposed by both psychological factors, including attachment disturbances and childhood trauma, and biological factors such as neuroplasticity and epigenetics. Current treatment recommendations include psychological therapy, with moderate effects observed with cognitive-behavioural therapy and psychodynamic therapy modalities, however, psychological understanding is key to success. The current case report describes cognitive analytic therapy (CAT) with a 68 year-old woman presenting to services with diagnoses of FND and borderline personality disorder (BPD). The target problem for therapy was integration of fragmented self-states (dissociative and driven) pertinent to both FND and BPD. 16 session CAT was delivered, with four follow up sessions, exploring unhelpful patterns of relating with self and others, based on an unconscious repertoire of internalised patterns and procedures from early life. CAT tools were used to facilitate change; reformulation and ending letters, mapping and the therapeutic relationship. Scores on the personality structure questionnaire (PSQ) and an idiosyncratic measure of state-shifting indicated positive outcomes, sustained at 3 month follow up. This shows modest early acceptability and feasibility of CAT for working with comorbid BPD and FND, providing a validating and blame free formulation of the development and maintenance of symptoms. Additional measures would have improved the ability to comment on the effectiveness of the treatment and future research implications are discussed.
Category Archives: Clinical Case Studies
Integrating Cognitive-Behavioral Therapy With Compassion-Focused Therapy for the Treatment of Social Anxiety Disorder: An Evidence-Based Case Study
Clinical Case Studies, Ahead of Print.
Cognitive-behavioral therapy (CBT) is an evidence-based treatment for social anxiety disorder that has been found to elicit significant changes in process-based mechanisms (e.g., emotion regulation strategies), which subsequently lead to reductions in social anxiety and associated functional impairment; however, CBT may be less effective for socially anxious individuals experiencing high self-criticism and low self-compassion. Compassion-focused therapy (CFT) has been used to address these tendencies in socially anxious individuals, but research in this area is limited. The present case study examined changes in social anxiety symptoms, self-compassion, emotion regulation strategies, and functional impairment throughout the course of treatment with a young, Chinese American woman using a novel integration of CBT and CFT for social anxiety disorder. The client experienced significant reductions in social anxiety and functional impairment across treatment, which was accompanied by reductions in fear and avoidance ratings for feared social scenarios. Significant mechanistic changes were also observed, including decreases in maladaptive emotion regulation strategies (i.e., suppression, rumination) and increases in self-compassion and adaptive emotion regulation strategies (i.e., expressive engagement, cognitive reappraisal). Findings support the efficacy of integrating compassion-focused strategies with CBT for social anxiety for a young adult with prominent tendencies of self-criticism and low self-compassion.
Cognitive-behavioral therapy (CBT) is an evidence-based treatment for social anxiety disorder that has been found to elicit significant changes in process-based mechanisms (e.g., emotion regulation strategies), which subsequently lead to reductions in social anxiety and associated functional impairment; however, CBT may be less effective for socially anxious individuals experiencing high self-criticism and low self-compassion. Compassion-focused therapy (CFT) has been used to address these tendencies in socially anxious individuals, but research in this area is limited. The present case study examined changes in social anxiety symptoms, self-compassion, emotion regulation strategies, and functional impairment throughout the course of treatment with a young, Chinese American woman using a novel integration of CBT and CFT for social anxiety disorder. The client experienced significant reductions in social anxiety and functional impairment across treatment, which was accompanied by reductions in fear and avoidance ratings for feared social scenarios. Significant mechanistic changes were also observed, including decreases in maladaptive emotion regulation strategies (i.e., suppression, rumination) and increases in self-compassion and adaptive emotion regulation strategies (i.e., expressive engagement, cognitive reappraisal). Findings support the efficacy of integrating compassion-focused strategies with CBT for social anxiety for a young adult with prominent tendencies of self-criticism and low self-compassion.
A Transdiagnostic Prevention Support Group for Caregivers of Children With Autism Spectrum Disorder: A Case Example
Clinical Case Studies, Ahead of Print.
Caregivers of children with autism spectrum disorder (ASD) experience increased levels of stress, anxiety, and depression compared to caregivers of neurotypical children. The high levels of stress and the prevalence of emotional disorders experienced by caregivers may negatively impact their capacity and confidence to effectively manage their child’s complex emotional and behavioral needs. Given these demands, caregivers of children with ASD require additional support to improve their psychological well-being and parenting self-efficacy. While support programs and treatments for children and adolescents with ASD are abundant, prevention programs that specifically targeted the emotional well-being of caregivers during the COVID-19 pandemic were limited. In this case paper, we describe Coping Options for Parent Empowerment (COPE), a prevention program for parents adapted from the Unified Protocols for Transdiagnostic Treatment of Emotional Disorders in Adults, Children, and Adolescents developed during the pandemic. To alleviate the stressors faced by caregivers during the pandemic and beyond, including increased caregiving responsibilities and financial difficulties, Project COPE targeted parent anxiety and depression through four brief, telehealth group sessions provided free of cost for caregivers of school-age children with ASD. In the case example presented, decreases in anxiety and depression, and increases in parent self-efficacy were reported after completing this program. Key insights about the intervention’s feasibility and content reported by parents are described. Findings suggest that the intervention removes some treatment access barriers typically seen in caregivers of children with ASD during and following the pandemic and that the program can be modified to increase engagement and acceptability.
Caregivers of children with autism spectrum disorder (ASD) experience increased levels of stress, anxiety, and depression compared to caregivers of neurotypical children. The high levels of stress and the prevalence of emotional disorders experienced by caregivers may negatively impact their capacity and confidence to effectively manage their child’s complex emotional and behavioral needs. Given these demands, caregivers of children with ASD require additional support to improve their psychological well-being and parenting self-efficacy. While support programs and treatments for children and adolescents with ASD are abundant, prevention programs that specifically targeted the emotional well-being of caregivers during the COVID-19 pandemic were limited. In this case paper, we describe Coping Options for Parent Empowerment (COPE), a prevention program for parents adapted from the Unified Protocols for Transdiagnostic Treatment of Emotional Disorders in Adults, Children, and Adolescents developed during the pandemic. To alleviate the stressors faced by caregivers during the pandemic and beyond, including increased caregiving responsibilities and financial difficulties, Project COPE targeted parent anxiety and depression through four brief, telehealth group sessions provided free of cost for caregivers of school-age children with ASD. In the case example presented, decreases in anxiety and depression, and increases in parent self-efficacy were reported after completing this program. Key insights about the intervention’s feasibility and content reported by parents are described. Findings suggest that the intervention removes some treatment access barriers typically seen in caregivers of children with ASD during and following the pandemic and that the program can be modified to increase engagement and acceptability.
Clinical Reflections and Treatment Adaptations for Avoidant Restrictive Food Intake Disorder: A Case Study
Clinical Case Studies, Ahead of Print.
Avoidant Restrictive Food Intake Disorder (ARFID) is a serious eating disorder, characterised by problematic eating habits that cause significant nutritional deficiencies. Having only been recently acknowledged as a distinct category, there is little research regarding best practice guidelines, especially among the adult population. In addition, ARFID often coexists with autism, and very little is known about how the diagnoses affect each other, further complicating treatment options. This case study reflects on the treatment of a young autistic woman with ARFID within an inpatient eating disorder setting. Using principles of food exposure, food trials were introduced as a way to increase food variety as well as overall nutrition. Results are promising, with the patient reaching a much safer weight and being able to increase her repertoire of food. While results are not generalisable to a wider population, it is hoped that similar approach could be used with other individuals who have ARFID and autism when aiming to increase nutrition and variety.
Avoidant Restrictive Food Intake Disorder (ARFID) is a serious eating disorder, characterised by problematic eating habits that cause significant nutritional deficiencies. Having only been recently acknowledged as a distinct category, there is little research regarding best practice guidelines, especially among the adult population. In addition, ARFID often coexists with autism, and very little is known about how the diagnoses affect each other, further complicating treatment options. This case study reflects on the treatment of a young autistic woman with ARFID within an inpatient eating disorder setting. Using principles of food exposure, food trials were introduced as a way to increase food variety as well as overall nutrition. Results are promising, with the patient reaching a much safer weight and being able to increase her repertoire of food. While results are not generalisable to a wider population, it is hoped that similar approach could be used with other individuals who have ARFID and autism when aiming to increase nutrition and variety.
Opening Treatment Windows for Treatment-Resistant Schizophrenia: Improving Emotion Regulation Strategies Using the Unified Protocol in a Case Study in Spain
Clinical Case Studies, Ahead of Print.
Approximately 30%-50% of people with schizophrenia worldwide have treatment-resistant schizophrenia (TRS). Currently available standard psychopharmacological and psychological treatments have proven insufficient to achieve full recovery in these patients. Alternative psychological interventions focused on improving emotion regulation, such as the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders (UP), could potentially improve treatment outcomes in this difficult to treat population. The aim of the present case study is to demonstrate how the UP can be adapted for the treatment of TRS. We decided to use UP to treat this particular patient due to the presence of intense unpleasant emotions, aversive reactions, and emotional avoidance strategies. After completing the full treatment protocol, the patient showed significant decreases in scores on the Difficulties in Emotion Regulation Scale (DERS), including total and emotional rejection, life interference, and emotional lack of control. A significant reduction was also observed in anxiety (OASIS) and depressive symptoms (ODSIS). The intervention had a positive impact on auditory hallucinations, with decreased severity, less intense anxiety, and less interference in life. The treatment led to greater control over voices and the patient reported feeling more confident in her relationship with those voices. These results provide preliminary support for the use of UP for the treatment of TRS.
Approximately 30%-50% of people with schizophrenia worldwide have treatment-resistant schizophrenia (TRS). Currently available standard psychopharmacological and psychological treatments have proven insufficient to achieve full recovery in these patients. Alternative psychological interventions focused on improving emotion regulation, such as the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders (UP), could potentially improve treatment outcomes in this difficult to treat population. The aim of the present case study is to demonstrate how the UP can be adapted for the treatment of TRS. We decided to use UP to treat this particular patient due to the presence of intense unpleasant emotions, aversive reactions, and emotional avoidance strategies. After completing the full treatment protocol, the patient showed significant decreases in scores on the Difficulties in Emotion Regulation Scale (DERS), including total and emotional rejection, life interference, and emotional lack of control. A significant reduction was also observed in anxiety (OASIS) and depressive symptoms (ODSIS). The intervention had a positive impact on auditory hallucinations, with decreased severity, less intense anxiety, and less interference in life. The treatment led to greater control over voices and the patient reported feeling more confident in her relationship with those voices. These results provide preliminary support for the use of UP for the treatment of TRS.
Disentangling the Consequences of Systemic Racism and Clinical Paranoia to Promote Effectiveness of a Cognitive-Behavioral Intervention for Persecutory Delusions in Minoritized Individuals: A Case-Example
Clinical Case Studies, Ahead of Print.
While everyone experiences threats, some threats are culturally specific and not universally recognized or addressed by providers. A prominent example is threat-based worry and hypervigilance in Black Americans and other minoritized individuals, which is higher due to systemic racism and increases risk for psychopathology like clinically significant paranoia. To date, there have been no adaptations of cognitive-behavioral therapies for Black Americans with psychosis, despite the long-standing history of systemic racism in the United States, and its increasingly recognized contribution to psychotic experiences. Accordingly, we present the first step towards developing an adapted cognitive-behavioral intervention for Black and minoritized Americans with psychosis. This adaptation of an empirically supported worry-based treatment for persecutory delusions was accomplished by comprehensive conceptualization and integration of how systemic racism and minoritization drive the prevalence and perception of threats. This contrasts with conceptualizing racism-related hypervigilance and cognitions as worry or ignoring these critical experiences altogether, which is invalidating and neglects optimal identification and intervention on behavioral targets. Using a validating and normalizing approach, the individual was able to identify how frequent threats related to systemic racism resulted in increased worry, vigilance, and distress. By identifying and intervening on the perception of threat and associated worry, the individual engaged in more helpful responses to the threat, which in turn increased participation in more meaningful activities and reduced worry and clinical paranoia. This case illustrates how accurate conceptualization clarifies behavioral targets and increases patient engagement, which together enhance the effectiveness of the intervention for minoritized individuals.
While everyone experiences threats, some threats are culturally specific and not universally recognized or addressed by providers. A prominent example is threat-based worry and hypervigilance in Black Americans and other minoritized individuals, which is higher due to systemic racism and increases risk for psychopathology like clinically significant paranoia. To date, there have been no adaptations of cognitive-behavioral therapies for Black Americans with psychosis, despite the long-standing history of systemic racism in the United States, and its increasingly recognized contribution to psychotic experiences. Accordingly, we present the first step towards developing an adapted cognitive-behavioral intervention for Black and minoritized Americans with psychosis. This adaptation of an empirically supported worry-based treatment for persecutory delusions was accomplished by comprehensive conceptualization and integration of how systemic racism and minoritization drive the prevalence and perception of threats. This contrasts with conceptualizing racism-related hypervigilance and cognitions as worry or ignoring these critical experiences altogether, which is invalidating and neglects optimal identification and intervention on behavioral targets. Using a validating and normalizing approach, the individual was able to identify how frequent threats related to systemic racism resulted in increased worry, vigilance, and distress. By identifying and intervening on the perception of threat and associated worry, the individual engaged in more helpful responses to the threat, which in turn increased participation in more meaningful activities and reduced worry and clinical paranoia. This case illustrates how accurate conceptualization clarifies behavioral targets and increases patient engagement, which together enhance the effectiveness of the intervention for minoritized individuals.
Dialectical Behaviour Therapy Enhanced Habit Reversal Training: A Clinical Case of Childhood-Onset Trichotillomania in an Adult With Impulsive Personality Features
Clinical Case Studies, Ahead of Print.
Research has recognised the psychosocial impairments linked to Trichotillomania (TTM) and established a relationship between problematic hair-pulling and affective regulation. Significant relationships between pulling triggers, their severity, and emotional dysregulation have also been predicted. The current case focused on the efficacy of combined DBT (Dialectical Behaviour Therapy) and HRT (Habit Reversal Training) in a client with TTM and Impulsive Personality features. The client received 11 weekly sessions of DBT-enhanced HRT, which took 3 months to complete. Following the end of this acute treatment phase, four maintenance sessions (two sessions per month) were delivered. The maintenance of treatment benefits was assessed using self-report measures and therapist observations at four time points: at pre-treatment, after the acute treatment phase (at the end of 3 months), and then at a 3-month and a 6-month follow-up. The intervention results suggested a substantial reduction in hair-pulling, hair regrowth in affected parts of the scalp, and self-reported improvements in mood. The study also shows preliminary evidence of DBT-enhanced HRT’s efficacy in a client with TTM and Impulsive Personality features, suggesting the importance of addressing personality structures and distressing emotional regulation that cause functional impairment during TTM treatment.
Research has recognised the psychosocial impairments linked to Trichotillomania (TTM) and established a relationship between problematic hair-pulling and affective regulation. Significant relationships between pulling triggers, their severity, and emotional dysregulation have also been predicted. The current case focused on the efficacy of combined DBT (Dialectical Behaviour Therapy) and HRT (Habit Reversal Training) in a client with TTM and Impulsive Personality features. The client received 11 weekly sessions of DBT-enhanced HRT, which took 3 months to complete. Following the end of this acute treatment phase, four maintenance sessions (two sessions per month) were delivered. The maintenance of treatment benefits was assessed using self-report measures and therapist observations at four time points: at pre-treatment, after the acute treatment phase (at the end of 3 months), and then at a 3-month and a 6-month follow-up. The intervention results suggested a substantial reduction in hair-pulling, hair regrowth in affected parts of the scalp, and self-reported improvements in mood. The study also shows preliminary evidence of DBT-enhanced HRT’s efficacy in a client with TTM and Impulsive Personality features, suggesting the importance of addressing personality structures and distressing emotional regulation that cause functional impairment during TTM treatment.
Differential Reinforcement Without Extinction and Stimulus Fading to Teach Tolerance of a Sleep Study
Clinical Case Studies, Ahead of Print.
There are a growing number of publications supporting behavior-analytic strategies to increase compliance with medical procedures. However, little research has been conducted on the application of applied behavior analysis to teach compliance with and completion of the setup required for an overnight sleep study (polysomnography). The client in this report presented with autism, cerebral palsy, epilepsy, strokes, and severe destructive behavior (i.e., aggression, property destruction, self-injury). These conditions combined with a poor sleep/wake schedule and gasping during the night necessitated a sleep study. The caregiver referred their child to behavioral outpatient services due to medical noncompliance and severe destructive interfering behaviors with similar procedures (e.g., failed electroencephalogram [EEG]). We evaluated the effects of differential reinforcement without extinction and stimulus fading on compliance and reduction of destructive behavior with a 25-step sleep study procedure. Our approach successfully taught tolerance of the procedure and reduced destructive behavior. The client completed the scheduled sleep study and received a diagnosis of mild obstructive sleep apnea.
There are a growing number of publications supporting behavior-analytic strategies to increase compliance with medical procedures. However, little research has been conducted on the application of applied behavior analysis to teach compliance with and completion of the setup required for an overnight sleep study (polysomnography). The client in this report presented with autism, cerebral palsy, epilepsy, strokes, and severe destructive behavior (i.e., aggression, property destruction, self-injury). These conditions combined with a poor sleep/wake schedule and gasping during the night necessitated a sleep study. The caregiver referred their child to behavioral outpatient services due to medical noncompliance and severe destructive interfering behaviors with similar procedures (e.g., failed electroencephalogram [EEG]). We evaluated the effects of differential reinforcement without extinction and stimulus fading on compliance and reduction of destructive behavior with a 25-step sleep study procedure. Our approach successfully taught tolerance of the procedure and reduced destructive behavior. The client completed the scheduled sleep study and received a diagnosis of mild obstructive sleep apnea.
Narrative Exposure Therapy for Treating Post-Traumatic Stress Among Transgender Youth of Color With Selective Mutism
Clinical Case Studies, Ahead of Print.
Rates of post-traumatic stress (PTS) are greater among transgender and non-binary (TGNB) youth compared to their cisgender peers. This disparity has been linked to increased experiences of trauma among TGNB youth, including greater exposure to child abuse, discrimination, hate crimes, and familial and peer bullying and rejection. Few studies to date have examined the use of trauma-focused interventions with TGNB youth. Narrative Exposure Therapy (NET) has been identified as a potentially impactful treatment for PTS for communities who experience oppression and human rights violations given its social justice-oriented “testimonial” approach and focus on meaning-making around traumatic experiences. While narrative-based approaches are often considered “best practice” for trauma interventions, youth may present with comorbid conditions that present barriers or often preclude them from receiving trauma treatment, such as selective mutism (SM). In this case series, we describe the use of NET for treating PTS symptoms in two transgender youth with comorbid SM, as well as adaptations to support their engagement and progress in treatment. Treatment progress was observed in reduction of PTS symptoms, increase in self-reported resilience and positive well-being, and full remission of SM, with treatment gains observed 6-months post-discharge. From these cases, we identified that (1) NET is a brief treatment that can address PTS and SM symptoms among TGNB youth; (2) NET is able to be adapted to enhance engagement in a narrative-based, trauma-focused therapy for youth with PTS and SM; and (3) NET can also increase self-perceived resilience and a sense of positive well-being for TGNB youth.
Rates of post-traumatic stress (PTS) are greater among transgender and non-binary (TGNB) youth compared to their cisgender peers. This disparity has been linked to increased experiences of trauma among TGNB youth, including greater exposure to child abuse, discrimination, hate crimes, and familial and peer bullying and rejection. Few studies to date have examined the use of trauma-focused interventions with TGNB youth. Narrative Exposure Therapy (NET) has been identified as a potentially impactful treatment for PTS for communities who experience oppression and human rights violations given its social justice-oriented “testimonial” approach and focus on meaning-making around traumatic experiences. While narrative-based approaches are often considered “best practice” for trauma interventions, youth may present with comorbid conditions that present barriers or often preclude them from receiving trauma treatment, such as selective mutism (SM). In this case series, we describe the use of NET for treating PTS symptoms in two transgender youth with comorbid SM, as well as adaptations to support their engagement and progress in treatment. Treatment progress was observed in reduction of PTS symptoms, increase in self-reported resilience and positive well-being, and full remission of SM, with treatment gains observed 6-months post-discharge. From these cases, we identified that (1) NET is a brief treatment that can address PTS and SM symptoms among TGNB youth; (2) NET is able to be adapted to enhance engagement in a narrative-based, trauma-focused therapy for youth with PTS and SM; and (3) NET can also increase self-perceived resilience and a sense of positive well-being for TGNB youth.
An Integrated Behavioral-Neuropsychiatric Treatment Plan Reduces Severe Challenging Behavior in an Adolescent With Neurobehavioral Complications of Neonatal Brain Injury
Clinical Case Studies, Ahead of Print.
We present the case of a 15-year-old adolescent boy with a neurobehavioral disorder who experienced a brain injury during the first month of life. The forms of challenging behaviors were severe and included aggression, property destruction, volitional incontinence, and suicidal statements, and had resulted in two psychiatric hospitalizations and multiple emergency evaluations prior to intervention. The intervention was preceded by a functional behavior assessment suggesting that a differential reinforcement intervention could be designed to minimize reinforcement of challenging behaviors while maximizing reinforcement of adaptive, positive behaviors. The intervention was introduced following the baseline phase and there was an immediate decrease in the rate of challenging behaviors and in the utilization of emergency psychiatric services. Improvements continued for 6 weeks, after which a medication was added to promote sleep onset (to decrease sleep onset latency) along with behavioral guidelines, which led to further improvements for an additional 12 weeks. A follow-up phase of 3 months showed sustained results. The study illustrates the value of an integrated approach utilizing applied behavior analysis and sequenced neuropsychiatry, and a neurobehavioral formulation where components of the participant’s brain injury history are integrated with an operant formulation as circumstances that explain the problem behavior while effectively suggesting strategies for behavioral treatment. Because the intervention was implemented by support staff in a group home, it illustrates the ability of support staff to work therapeutically with severe behavior presentations using structured behavioral interventions.
We present the case of a 15-year-old adolescent boy with a neurobehavioral disorder who experienced a brain injury during the first month of life. The forms of challenging behaviors were severe and included aggression, property destruction, volitional incontinence, and suicidal statements, and had resulted in two psychiatric hospitalizations and multiple emergency evaluations prior to intervention. The intervention was preceded by a functional behavior assessment suggesting that a differential reinforcement intervention could be designed to minimize reinforcement of challenging behaviors while maximizing reinforcement of adaptive, positive behaviors. The intervention was introduced following the baseline phase and there was an immediate decrease in the rate of challenging behaviors and in the utilization of emergency psychiatric services. Improvements continued for 6 weeks, after which a medication was added to promote sleep onset (to decrease sleep onset latency) along with behavioral guidelines, which led to further improvements for an additional 12 weeks. A follow-up phase of 3 months showed sustained results. The study illustrates the value of an integrated approach utilizing applied behavior analysis and sequenced neuropsychiatry, and a neurobehavioral formulation where components of the participant’s brain injury history are integrated with an operant formulation as circumstances that explain the problem behavior while effectively suggesting strategies for behavioral treatment. Because the intervention was implemented by support staff in a group home, it illustrates the ability of support staff to work therapeutically with severe behavior presentations using structured behavioral interventions.