Psychotherapy With Trauma and Stressor-Related Disorders
Youtube Video
Grande, T. (2019, August 21). Presentation example: Posttraumatic stress disorder (PTSD) [Video]. YouTube.
TRANSCRIPT
welcome to my scientifically informed
00:01
insider look at mental health topics if
00:04
you find this video to be interesting or
00:06
helpful please like it and subscribe to
00:07
my channel oh this is dr. Grande today’s
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question is can I analyze a presentation
00:13
example for post-traumatic stress
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disorder
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specifically can I look at an example
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where the trauma did not seem to be
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congruent with the development of the
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disorder so another way of putting that
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is the trauma didn’t really seem that
00:27
severe when it happened yet it’s still
00:30
led to post-traumatic stress disorder so
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when I use the term presentation example
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what I’m talking about is a situation
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where a mental health therapist like a
00:41
counselor wants to take the information
00:44
from a client’s case from a client’s
00:47
presentation and produce a report from
00:50
that so this is also called a
00:53
presentation analysis case analysis or a
00:57
case study after the clinician obtains
00:59
consent they produce this report but
01:01
they change a lot of the identifying
01:03
information not only the clients name
01:05
but a lot of other information but the
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idea here is that the clinical essence
01:09
of the case remains unchanged so we can
01:13
learn something from it as clinicians
01:15
and as people that are not clinicians
01:18
but we still don’t know who it is right
01:20
doesn’t have identifying information
01:22
about the client typically these are
01:25
used in training other types of
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education conferences and sometimes
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these case reports are published the
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presentation example I’m using here did
01:34
come from a published study and I’ll put
01:36
the reference to this article in the
01:38
description for this video this is an
01:40
interesting presentation example it’s of
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an eight-year-old boy I’ll call him Joe
01:44
this takes place in the United Kingdom
01:48
this is a good example of how a
01:50
traumatic event might not seem severe
01:52
but how it’s the interpretation that can
01:55
lead to post-traumatic stress disorder
01:57
it’s also a good example of how trauma
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focused cognitive therapy can be used to
02:02
treat post-traumatic stress disorder one
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of the mysteries of post-traumatic
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stress disorder is why does it tend to
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form in some people who have relatively
02:12
minor of
02:13
massacre when it might not form and
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other people have really serious events
02:19
occur right so for example a severe
02:22
motor vehicle accident compared to a
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minor motor vehicle accident and that’s
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what we’re talking about here in this
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case a minor motor vehicle accident well
02:29
we learn here of course is it’s not just
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the severity of the traumatic event that
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matters there are a number of other
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factors that have to be weighed in
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genetic factors environmental factors
02:40
prior experiences cognitive processing
02:43
and what was perceived during the event
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so first I’ll review Joe’s history then
02:49
take a look at trauma focused cognitive
02:50
therapy and then look at the course of
02:53
treatment in this case so again Joe is 8
02:56
years old he lives with his father and
02:59
two older siblings Joe’s father takes
03:01
care of the three children alone as his
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wife left him many years ago Joe’s
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father has a physical disability but no
03:09
history of mental health conditions now
03:11
taking a look specifically at the
03:13
traumatic event I mentioned it was a
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minor motor vehicle accident we see that
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Joe was riding home as a passenger in
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the front seat of his father’s car his
03:21
father was driving they were coming back
03:23
from soccer practice and his father
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entered into a traffic circle in this
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case it was a five-way intersection the
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father slows down as he sees another
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vehicle in the circle so he has to yield
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to that vehicle because either the
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vehicle has the right of way
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and as the father slows down the vehicle
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behind him runs into the rear of his
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vehicle the guy behind him was driving
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too fast not paying attention whatever
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was going on there but again he drove
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into Joe’s father’s car so Joe was not
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hurt at all Joe’s father sustained a
03:56
minor injury to his knee because it hit
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the steering column there was no airbag
04:00
deployment the vehicle is only
04:02
cosmetically damaged and it was drivable
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immediately after the collision
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evidently when Joe’s father exited the
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vehicle to talk to the driver that hit
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them an argument ensued and the other
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driver threatened Joe’s father with
04:17
physical harm so Joe’s father got back
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into the vehicle and drove away from the
04:21
scene but the other driver pursued them
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before eventually breaking off the
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pursuit by pulling over on
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the road Joe’s father waited till they
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arrived home before he called the police
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shortly after this event Joe was taken
04:33
in to receive mental health care he
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presented with intrusive memories of the
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accident and the subsequent pursuit he
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did not seem to understand the incent
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but he did understand that was an
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accident
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and the car was slightly damaged and he
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also understood that the other driver
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chased him and his father Joe we become
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very anxious when presented with
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anything that reminded him of the
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accident the stretcher Road word
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occurred stories on television related
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to car accidents the type of vehicle
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that hit them and talking about the
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insect Joe had trouble sleeping it took
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him a few hours to get to sleep and had
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to go to sleep in the same room as his
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dad to fall asleep he also had a lot of
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nightmares
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he became physically aggressive in
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school and at home at school he was
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engaging in outburst in the middle of
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class it was one incident where he
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turned over tables and threw trash all
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around the classroom and apparently this
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was pretty frightening to the school
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staff and to his fellow students at home
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he was fighting with older siblings and
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was set off by the slightest
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provocations in addition to meeting the
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criteria for post-traumatic stress
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disorder Joe had significant comorbidity
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including oppositional defiant disorder
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conduct disorder that’s really uncommon
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that both of those diagnoses would be
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given he also had major depressive
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disorder attention deficit hyperactivity
05:55
disorder ADHD separation anxiety
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disorder and one specific phobia spiders
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the only diagnoses that were of concern
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before the incident would be the ADHD
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and the fear of spiders all the other
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diagnoses were given after the event
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that’s a lot of mental disorders to be
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diagnosed with that quickly I’ll talk
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about this a little later specifically
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at the post traumatic stress disorder we
06:20
see Joe had symptoms of hyper or
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avoidance and intrusive thoughts he also
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had a disorganized understanding of the
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event and didn’t really seem to be able
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to discuss the incident so now take a
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look at the trauma focused cognitive
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therapy a key concept of this therapy
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when talking about PTSD
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is the nature of the traumatic memory
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not so much what happened but again the
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properties of the actual memory it’s
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considered to be critical to the
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development of PTSD individuals with
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PTSD often struggle to retrieve
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information about the event when they do
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recall information it’s often fragmented
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and disorganized as I mentioned this is
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something of course we see specifically
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in this case with Joe another important
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concept is the idea of maladaptive
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appraisals so an individual PTSD is
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unable to accurately assess the event
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and the idea that the event was time
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limited so they don’t really understand
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that the event is in the past but it’s
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over this leads to the sense that
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there’s some sort of current threat
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right again so the traumatic event is
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not just in the past but it’s happening
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right now in some way or it may happen
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right now in some way to address these
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concepts and the other factors we see
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around PTSD trauma focused cognitive
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therapy focuses on the 3ms of PTSD
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memories
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distorted memory representations
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meanings the maladaptive cognitive
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appraisals and management this is
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working on the difficulty we see with
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coping with feelings and thoughts and
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perceptions so now moving to the course
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of treatment we see in this case of Joe
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the treatment team explained to Joe how
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the treatment was supposed to work so
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they explained the three M’s and all the
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other information about trauma focused
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cognitive therapy we see that Joe’s
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father joined him for the early sessions
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this kind of makes the client more
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comfortable in the case of Joe it
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certainly did these initial sessions had
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a lot of normalizing of the response to
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the event so anybody would be distressed
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if they are in a car accident and
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pursued by the person that hit them
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there was a lot of rapport building they
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made it clear to Joe that he had
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permission to talk about the event which
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I think seems particularly bored in this
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case because again he had difficulty
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really expressing thoughts or feelings
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around the incident they also gave him
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permission to talk about the symptoms
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and they discussed the incident in a
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calm and safe way kind of setting at
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for joe tafolla trying to really make
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this a little bit less emotional for Joe
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Joe was encouraged to recognize his
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emotions to express his emotions and to
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manage the more extreme emotional
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reactions some relaxation techniques
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were used including progressive muscle
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relaxation Joe was also instructed to
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practice this at home so we see some
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homework assigned which is actually
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fairly common for all different types of
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cognitive therapy we see the specific
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cognitive distortion was identified
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early on this is that Joe believed that
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the world was a different place since
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the accent in relation to him right so
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he didn’t fit in with the world in the
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same way because of that accent
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Joe was assigned a number of new
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activities this is called behavioral
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activation essentially we see a series
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of tasks that Joe and his father would
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complete together for example they would
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play soccer in the garden then in the
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street and then play soccer in the park
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the idea here was they’re trying to move
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Joe into other geographic areas and
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increased the probability of contact
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with his friends from these behavioral
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activation exercises it became clear
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that one of Joe’s fears was that when he
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was away from his father something bad
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would happen to his father to alleviate
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this fear they discussed with Joe how
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his father – actually been a number of
10:18
altercations before this incident they
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tried to sell this like Joe’s father had
10:24
a lot of skill at surviving fights so it
10:27
always worked out okay for him because
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he knew how to take care of himself I’m
10:31
not sure I would have gone with this
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route right like telling Joe that his
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father had been in a lot of fights and
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kind of was a survivor it seems a little
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unusual to me it’s kind of introducing
10:43
new information that may have backfired
10:45
but we see in the case report that this
10:47
appears to have been effective again
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maybe not something I would have done
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but a kind of maneuver that seemed to
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work in this case Joe also incorrectly
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believed that his father was still
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suffering from the injuries that
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occurred in the accent what we see is
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that Joe became more alert about
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behavior as his father already engaged
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in for example taking medication the
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father already did this right
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early but now Joan noticed it and
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attributed this behavior to the accent
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so Joe had a lot of blanks in terms of
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understanding what happened and he
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tended to fill in those blanks with the
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worst case scenario the treatment team
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kind of created a game for Joe to
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address this making him the detective
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who is responsible to find evidence and
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fill in those blanks so unlike that
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other technique of talking about all
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these flights that the father had been
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in I think this technique makes a lot of
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sense
11:39
this one really I think kind of empowers
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Joe and allows him to use his creativity
11:44
and critical thinking skills to solve
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problems that could help him move past
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these symptoms so I really like this
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technique in particular we see an
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example of some of the blanks that Joe
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had in terms of the narrative Joe
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believed that immediately after the
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accent that him and his father were both
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severely injured so severely in fact he
12:05
believed they required immediate medical
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treatment because they did not receive
12:09
treatment Joe felt that there must be
12:11
unresolved physical issues so he
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believed that both him and his father
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had physical problems as a result of
12:18
that accent but really it was a
12:20
cognitive distortion they did not have
12:22
any problems at the time that Joe was
12:24
receiving treatment so to address this
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they talked with Joe about his
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understanding what happened and in the
12:31
narrative we see that behind the vehicle
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that hit Joe and his father there was an
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ambulance the ambulance crew saw the
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accident of course they were right
12:39
behind the vehicle to hit him as I
12:40
mentioned but then they drove past the
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accent drove around the circle and came
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back to make sure that no one was
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injured to the degree where they would
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need transportation to the hospital Joe
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remembers seeing the ambulance twice
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which is in fact what happened the
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ambulance passed their position again
12:59
two times going past them and then
13:01
coming back the presence of that
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ambulance led to this assumption by Joe
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that he would need to be hospitalized
13:07
therefore his injuries must have been
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serious so again we kind of see how
13:12
these cognitive sources play out there
13:15
was information that was accurately
13:17
collected at the time by Joe but
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incorrectly interpreted
13:22
the treatment team was able to spin this
13:24
around and paint another narrative I
13:26
thought this was also a good technique
13:27
they said clearly it was unlikely that
13:30
Joe and his father were severely injured
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as evidenced by the ambulance crew
13:34
seeing them and continuing on so they
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really took the same information but
13:40
interpreted more accurately and in a way
13:42
that was more helpful to treating Joe’s
13:44
symptoms Joe made fairly good progress
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as a result of therapy
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there was this distress scale that they
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used in therapy and went from 0 to 10
13:53
with 10 being the most distressed Joe
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initially reported a score of 10 when
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discussing the incident but by the time
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he got to the end of therapy he was
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reporting scores of 0 during all parts
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of his narrative not just the parts
14:07
associated low distress but even the
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parts that have been associated with a
14:11
high level distress my thoughts on this
14:13
presentation example this is an
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interesting case we get to see as I
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mentioned before how severity may be
14:19
important sometimes but it may not be
14:21
the most important thing for everybody
14:23
and it would also appear here that the
14:25
altercation was as traumatic as the
14:28
accent so I think that’s what’s really
14:30
interesting about this as well we see
14:33
this accent that was fairly minor right
14:35
Joe was uninjured but then we see this
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pursuit and that as a separate incident
14:41
could be quite frightening and it’s
14:43
really again how somebody perceives that
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pursuit I think most people would have
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been fairly alarmed when being chased by
14:51
another car but by the accident itself I
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think most people would not have viewed
14:56
that as traumatic when these things
14:58
combined for Joe it did result again in
15:01
the development of post-traumatic stress
15:02
disorder
15:03
we’re also left with the sense that if
15:06
Joe didn’t realize that they were being
15:08
chased he would not have been
15:09
traumatized right so maybe the motor
15:12
vehicle accident really wasn’t enough to
15:14
lead to PTSD but it was his
15:16
interpretation of that pursuit which of
15:19
course as I mentioned would have been
15:20
scary to anybody but if he was sitting
15:22
there and didn’t know about it he may
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not have had any reaction to it now
15:26
there’s not a strategy that comes from
15:29
this of course there’s no way to really
15:30
say hey let’s ignore what’s going on
15:32
right Joe’s father couldn’t have just
15:34
said hey nothing’s really happening here
15:36
not worry about it he had to acknowledge
15:38
what was going on and he was probably
15:39
scared himself but again it just points
15:42
back to how important perception is I
15:44
mentioned before that it seemed like Jo
15:46
was given a large number of diagnosis I
15:48
have to in some sense of course defer to
15:51
the people that treated him because they
15:53
actually saw him and they put together
15:54
this case report but I can’t help
15:56
thinking that it may have been more
15:58
useful to diagnose him just with
16:01
post-traumatic stress disorder and treat
16:03
that for a while
16:04
rather than stacking on a lot of
16:06
diagnoses the one that concerns me the
16:08
most of course is that conduct disorder
16:10
diagnosis conduct disorder carries a
16:13
stigma because about a third of
16:15
individuals diagnosed with it will go on
16:18
to develop antisocial personality so I
16:20
think I would have tried to avoid the
16:22
conduct disorder diagnosis especially
16:24
because the oppositional defiant
16:26
disorder was already diagnosed as I
16:29
mentioned before it’s unusual to have
16:30
both of those diagnoses together usually
16:33
it’s just one or the other of course
16:35
somebody can technically be diagnosed
16:37
with both but again this is somewhat
16:38
unusual and if you have the o DD
16:41
diagnosis there I don’t really see the
16:43
urgency to go ahead and move forward
16:45
with conduct disorder but again that’s
16:47
just my opinion for me in the case
16:48
report there’s a lot of information of
16:50
course that would not be included there
16:52
of less concern but still somewhat
16:54
troubling is the diagnosis of major
16:56
depressive disorder this is an episodic
16:59
disorder that has a distinct course to
17:02
it somebody has a major depressive
17:03
episode then they usually recover some
17:06
degree and sometime later they have
17:08
another major depressive episode usually
17:10
sometimes there’s one episode but
17:11
usually there’s more than one so this
17:13
isn’t something that we really think of
17:15
as being associated with a traumatic
17:18
event like a traumatic event occurs and
17:20
then immediately after that we see major
17:22
depressive disorder this is a disorder
17:24
where you would typically take a lot of
17:26
time before making the diagnosis watch
17:29
somebody for a while see if there’s some
17:31
sort of change in their mood look at the
17:35
level of depression and the level of
17:37
some of the other symptoms associate the
17:38
disorder so a little bit unusual I think
17:42
to jump right to major depressive
17:43
disorder as well so we see kind of I
17:45
think some unusual diagnostic behave
17:49
on the part of the clinicians not
17:51
necessarily technically incorrect but
17:53
just unusual I thought this presentation
17:55
example overall though was excellent and
17:57
demonstrating how trauma focused
17:58
cognitive therapy could be applied to a
18:01
real-life situation and how cognitive
18:03
distortions were highly problematic for
18:06
Joe and addressing those distortions
18:08
seemed to lead to a market improvement
18:12
PTSD and part is driven by individual
18:15
perceptions it’s what people think of
18:17
those events that really matters at
18:19
least in some cases so I know whenever I
18:22
talk about topics like this like
18:23
post-traumatic stress disorder and I
18:25
look at these different presentation
18:27
examples there gonna be a variety of
18:28
opinions please put any opinions and
18:31
thoughts in the comment section
18:32
they always generate a really
18:34
interesting dialogue as always I hope
18:35
you found this presentation example on
18:37
post-traumatic stress disorder and
18:38
trauma focused cognitive therapy to be
18:41
interesting thanks for watching
<b>The Assignment
Succinctly, in 1–2 pages, address the following:
1- Briefly explain the neurobiological basis for PTSD illness.
2- a-Discuss the DSM-5 diagnostic criteria for PTSD and relate these criteria to the symptomology presented in the case study.
b- Does the video case presentation provide sufficient information to derive a PTSD diagnosis? Justify your reasoning.
c- Do you agree with the other diagnoses in the case presentation? Why or why not?
3- a-Discuss one other psychotherapy treatment option for the client in this case study.
b-Explain whether your treatment option is considered a “gold standard treatment” from a clinical practice guideline perspective, and why using gold standard, evidence-based treatments from clinical practice guidelines is important for psychiatric-mental health nurse practitioners.
4-a-Support your Assignment with specific examples from this week’s media and at least three peer-reviewed, evidence-based sources.
b-Explain why each of your supporting sources is considered scholarly.
c-Attach the PDFs of your sources.
Book Reference: Wheeler, K. (Ed.). (2020). Psychotherapy for the advanced practice psychiatric nurse: A how-to guide for evidence-based practice (3rd ed.). Springer Publishing.
Chapter 3, “Assessment and Diagnosis” (Previously read in Week 2)
Chapter 7, “Eye Movement Desensitization and Reprocessing Therapy”
Chapter 11, “Trauma Resiliency Model Therapy”
Chapter 15, “Trauma-Informed Medication Management”
Chapter 17, “Stabilization for Trauma and Dissociation”
Chapter 18, “Dialectical Behavior Therapy for Complex Trauma”
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