Clinical Case Studies

The current case study highlights the treatment of “Thelma,” a 48-year-old woman of African American and Hispanic descent who was diagnosed with borderline personality disorder (BPD), major depressive disorder, post-traumatic stress disorder, and bulimia. An attachment theory approach was used to elicit core structure change in Thelma's BPD symptoms after traditional modern cognitive approaches proved ineffective. It was hypothesized that treating her Axis II disorder would actually serve to reduce her Axis I symptoms. The attachment approach entailed a shift toward second-order change processes, a shift away from problem-solving approaches, a focus on the quality and intensity of the relationship, and a more relaxed approach to boundary setting in the context of treatment. The approach did appear to reduce many Axis I symptoms including self-mutilation, suicidal ideation, and binging and purging behaviors and appeared to improve her interpersonal functioning.

This case study applies feminist identity development (FID) theory to a feminist-oriented psychotherapy treatment. Although there is a strong body of literature on the principles of feminist psychotherapy, the concept of FID must be further integrated into this work. As a link between psychiatric symptoms and different levels of FID has been empirically supported, FID has a natural connection with psychotherapeutic treatment. This case presentation follows Tara, a working-class woman in her midtwenties, who initially presented in psychotherapy with symptoms of anxiety, depression, and some indication of thought disorder. During her 3½ year treatment, she confronted issues of her mental health, employment and education, and issues related to pregnancy, childbirth, and parenting. These topics were addressed in the context of Tara's emerging understanding of her identity as a woman in a patriarchal society. Attention to issues related to FID facilitated understanding of key issues in treatment.

In isolation, bipolar disorder and dissociation can place adolescents at risk of self-harm or suicide. However, when these are combined, they place an adolescent at serious risk of self-harming behavior or suicide completion. It appears from the scarcity in the literature to be rare for adolescents to have the combination of bipolar disorder and dissociation. This article outlines the case of an older adolescent girl with a comorbid combination. This case study highlights how the comorbidity of bipolar disorder and dissociation increases a patient's lethality risk and how both disorders may contribute to the volatile destabilization of the other. Risk management strategies are proposed in relation to the assessment of risk and preparedness for discharge from inpatient facilities.

The development and maintenance of posttraumatic stress disorder (PTSD) can be understood as a function of learning and cognitive processes. This case report addresses treatment of PTSD with a 72-year-old former police officer who was experiencing intrusive thoughts, nightmares, experiential and affective avoidance, and hyperarousal resulting from witnessing a series of traumatic events during his time in law enforcement. Although the latency between events and treatment was more than 20 years, this patient was responsive to a cognitive-behavioral, exposure-based treatment. Several other factors, including the client's age and chronic pain, complicated this case. The aim of this study was to identify the conceptual framework for treatment, explore the course of therapy, and identify socially valid means of treatment and assessment in outpatient therapy. At the termination of treatment, this patient evidenced improvements in overall anxiety, depressive symptoms, and frequency and severity of PTSD symptoms. Recommendations for clinicians and treatment implications are also presented.

Depression is frequently observed among young mothers who are low income who participate in home visitation programs that are focused on optimizing child development. Maternal depression can undermine such prevention programs, and mothers are faced with significant barriers to obtaining concurrent effective mental health treatment. This case study describes In-Home Cognitive Behavior Therapy (IH-CBT), an adapted treatment for depressed mothers in home visitation. IH-CBT provides an empirically based treatment in the home setting that is tightly integrated with ongoing home visitation. The treated mother presented with major depressive disorder in the postpartum period and poor attachment with her baby. After 15 sessions of IH-CBT, provided in conjunction with home visitation, significant improvement occurred in mood, self-sufficiency, and her relationship with her baby.

Habit reversal (HR) is a multicomponent treatment for tic disorders. This case study incorporated elements of HR (awareness training, self-monitoring, response competition), combined with relaxation, as an intervention for vocal and motor tics in a 10-year-old boy with Tourette's syndrome (TS). Therapy was provided on an outpatient basis at a pediatric clinic. In-home data collection by the boy's mother documented decreased tic frequency during the course of treatment. Clinical improvement was maintained at a 3-month follow-up. These results support previous research demonstrating efficacy of simplified HR in controlling multiple tics associated with TS.