CASE 1: POST TRAUMATIC STRESS DISORDER—SOFIA 1. What event precipitated Sofia’s PTSD?
ANSWER: Sophia was involved in an accident on the subway in which she received injury to her knee and temporary unconsciousness. The fact that several others were injured and she spent several hours in the emergency room area observing other traumatic injuries, before she could be examined by a physician, caused her to develop a stress reaction. (pp. 4–5)
2. Survivors of severe stress often have abnormal activity of which neurotransmitter and which hormone?
ANSWER: “Studies indicate that survivors of severe stress, especially those who develop stress disorders, experience abnormal activity of the neurotransmitter norepinephrine and the hormone cortisol.” (p. 6)
3. Why do friends and relatives eventually distance themselves from a person who has experienced a traumatic incident?
ANSWER: Individuals many times feel the need to repeat their traumatic experience over and over again, such as Sophia did with her friend Fiona. However Sophia, by focusing mainly on her trauma and becoming in Fiona’s words “an obsessive self-centered woman,” began to drive her friends away. (pp. 7–8)
4. Why did Sofia finally decide to seek treatment?
ANSWER: Sophia’s life became more isolated with the loss of friends and she became fearful when an orthopedic doctor suggested she might need surgery on her injured knee. Her extreme reaction to the suggestion of surgery prompted the physician to encourage her to seek the help of a psychologist. (pp. 8–9)
5. Why did the doctor diagnose Sofia with post-traumatic stress disorder rather than acute stress disorder?
ANSWER: First she had been exposed to a traumatic event that posed a threat of death or serious injury. Second, the traumatic event was persistently re-experienced. Third, Sophia avoided stimuli associated with the trauma. Fourth, she exhibited persistent symptoms of increased arousal, sleep difficulties, hypervigilance, and exaggerated startle response. Finally, her symptoms had been continuing over a 5 month period (more than one month). (p. 9)
6. What modes of therapy did Dr. Fehrman select to assist Sofia with her disorder? Give an example of each type of therapy.
ANSWER: Dr. Fehrman selected both behavioral and cognitive approaches. The behavioral approach involves exposing a person—with either in vivo or imaginal exposure to anxiety-producing stimuli. The cognitive approach, called cognitive restructuring, guides the individual to think differently about the trauma itself. (p. 9)
Examples: In vivo involves creating a hierarchy of anxiety-provoking situations ranging from least threatening to most threatening. Both the therapist and the client work together to create this hierarchy. A step-by-step approach is used until the most feared activity on the hierarchy is mastered by the client.
In imaginal exposure the therapist has the client repeatedly visualize the sequence of events surrounding the trauma until the client becomes desensitized to the traumatic event.
Cognitive restructuring challenges the client’s accuracy of the negative cognitions and uses these statements in connection with the exposure exercises. (pp. 10–11)
7. During the first session, Dr. Fehrman gave Sophia three components of how her therapy would progress. Describe those three components.
ANSWER: a. Sophia was to survey how her life had changed by her current fears and anxieties, paying particular attention to how her former activities had been curtailed. Together they would create a hierarchy of activities from least to most feared. Sophia would then begin to repeatedly expose herself to these situations until improvements were seen.
b. Sophia would be repeatedly exposed to the traumatic memory of the event so that eventually her emotional reaction to the memory would be reduced.
c. Sophia was asked to take note of the activities she was avoiding so that a hierarchy of in vivo behavioral exercises could begin. (pp. 10–11)
8. What was the purpose of tape-recording the traumatizing incident?
ANSWER: By taping the memory of the traumatic event, Dr. Fehrman was able to have Sophia participate in imaginal exposure, help her to see that her anxiety could be reduced by the end of the recording, and challenge some of the negative assumptions she had created about the incident. (pp. 12–13)
9. Why did Sophia fail to take notes of her feared activities as part of her treatment plan? How did Dr. Fehrman handle this problem in his session with Sofia?
ANSWER: She was too consumed with anxiety about whether to have surgery on her knee. Dr. Fehrman suggested that since the orthopedist had not indicated an emergency situation, she should focus on her stress-related disorder for the next month and revisit her concern regarding her knee at a later date. (p. 11)
10. What other incident in Sofia’s early life may have contributed to her PTSD?
ANSWER: She had once been completely subjugated to the Nazi authorities for several days while temporarily imprisoned in a labor camp. (pp. 12–13)
11. According to the text, what is the average length of time before symptoms begin to decrease after the traumatic event? Is there a difference between an individual who receives treatment and someone who does not?
ANSWER: “According to one survey, post-traumatic stress symptoms last an average of 3 years with treatment, but 5 1/2 years without treatment (Kessler & Zhao, 1999).” (p. 14)
CASE 2: PANIC DISORDER—JOE1. In the case of “Joe,” what event precipitated his panic attack?
ANSWER: Joe and Florence, his wife, were returning from a Florida vacation. After the airplane took off in Miami, Joe began having difficulty breathing and feeling as if he was being deprived of oxygen. (p. 19)
2. Why is Joe’s case different from most panic attacks?
ANSWER: “Unlike Joe’s case, panic disorder usually first begins between late adolescence and the mid-30s.” (p. 19)
3. What are the symptoms of most panic attacks? ANSWER: See list on p. 17, Table 2-1. The DSM-IV Checklist
4. Why do individuals first suspect a general medical condition?
ANSWER: Symptoms of a panic attack often mimic symptoms of a heart attack. Other disorders that have similar symptoms are thyroid disease, seizure disorders, cardiac arrhythmias, and mitral valve prolapse. (p. 22)
5. Why was Dr. Geller convinced that panic disorders are “best explained by a combination of biological and cognitive factors”?
ANSWER: On the biological side, she believed that panic attacks are similar to the fight-orflight response, the normal physiological arousal experienced by humans and animals as a response to danger. However, in the case of panic attacks there is no real external threat. So a panic attack is seen as a false alarm of the fight-or-flight response. On the cognitive side, individuals may interpret the attacks as a real physiological threat rather than a false alarm and conclude that the physiological arousal is a real, rather than an imagined, physical threat. (p. 23)
6. Describe the four steps Dr. Geller decided to take to help Joe overcome his panic attacks?
ANSWER: (pp. 25–29)
a. Training in relaxation and breathing techniques—Joe was taught progressive muscle relaxation technique as well as breathing control exercises and practiced these with tape-recorded instructions. (p.26)
b. Changing his cognitive misinterpretations of panic sensations—when sensations of the panic attack would begin, Joe was to remind himself that he was not in any physical danger.
c. Repeated exposure to sensations of panic under controlled conditions—Joe was introduced to interoceptive exposure techniques. Joe’s specific exercises were to shake his head from side to side for 30 seconds, stare at a spot on the wall for 90 seconds, and hyperventilate for 60 seconds.
d. Repeated practice in situations where Joe was currently apprehensive or avoidant—Joe had to travel alone on the subway to his appointment with Dr. Geller.
7. List and describe three separate interoceptive exposure exercises.
ANSWER: Any three from Table 2-3 on p. 28. The answer should include not only the activity, but also the duration.
8. What was the final outcome for Joe? ANSWER: Joe was able to take a trip to Europe without any symptoms of panic disorder. (p. 29)
CASE 3: OBSESSIVE COMPULSIVE DISORDER—SARAH 1. When do obsessive-compulsive behaviors usually begin for most individuals?
ANSWER: “Obsessive-compulsive disorder usually begins in adolescence or early adulthood, although it may begin in childhood (APA, 1994, 2000).” (p. 31)
2. What were Sarah’s primary obsessions and compulsions? ANSWER: Sarah’s primary obsessions (worries) regarded safety issues, and her compulsions
(actions) were the constant checking behaviors. (pp. 31–34)
3. Why did Sarah finally decide to seek treatment?
ANSWER: Her constant anxieties and checking behaviors were interfering with her relationship with her fiancé, Jim. (p. 35)
4. What type of therapy did Dr. Laslow decide to try to help Sarah overcome her OCD?
ANSWER: Dr. Laslow decided to use a behavioral approach, exposure, and response prevention. (p. 36)
5. Dr. Laslow asked Sarah to keep a diary of her obsessions and compulsions. What did Sarah learn from her record-keeping and how did Dr. Laslow use this information to assist in her treatment program?
ANSWER: Sarah learned that she had three separate categories of obsessive-compulsive anxieties: household activities, driving, and anxieties over destructive thoughts and imagery. Dr. Laslow used these specific anxieties to set up his exposure and response prevention exercises. (pp. 38–43)
6. What was the purpose of tape-recording Sarah’s visually imagined “disaster” scenes?
ANSWER: Sarah was to listen to the recording until she began to become less reactive to its content. (p. 40)
7. How many sessions did it take for Sarah to overcome her household obsessions and compulsions?
ANSWER: By the 7th session, Sarah’s household obsessions and compulsions had virtually been eliminated. (p. 41)
8. Obsessions may take different forms. List three different forms cited in the text. ANSWER: (p. 42)
b. Impulses c. Images
9. How many sessions were necessary for Sarah to overcome her OCD to household and driving issues? ANSWER: At session 14 Sarah reported her first week of normal life. (p.43)
CASE 4: MAJOR DEPRESSIVE DISORDER—CARLOS 1. For individuals with depression, what are the first signs that indicate they might be depressed?
ANSWER: Individuals often first think they have a physical illness. Page 47 states, “Forty-one percent of persons with depression initially go to a physician with complaints of feeling generally ill, 37% complain of pain, and 12% report fatigue (Katon & Walker, 1998).”
2. Why did Carlos initially see his family physician?
ANSWER: Carlos became increasingly preoccupied with his health after a cousin had a fatal heart attack. (p. 47)
3. What symptoms did Carlos present that prompted his family physician to suggest a psychologist?
ANSWER: After examining Carlos for any physical abnormalities, and finding that Carlos was in good physical health, the doctor felt that Carlos’ concern about having a heart attack was “getting out of hand.” When he told Carlos to stop worrying, Carlos began to cry, leading the doctor to feel that Carlos’ concern was more than just a physical problem. (pp. 47–48)
4. Why did his psychologist, Dr. Willard, recommend a psychiatrist?
ANSWER: Dr. Willard felt that Carlos might benefit from antidepressant medication, which could be prescribed by a psychiatrist (a medical doctor who specializes in mental disorders). (p. 48)
5. What was the initial antidepressant prescribed, and why did Carlos decide not to continue taking this medication?
ANSWER: Dr. Hsu, the psychiatrist, started Carlos on 2 capsules of fluoxetine (Prozac) per day. Carlos reported that he was having side effects that made him feel “like he was about to jump out of his skin.” (p. 48)
6. Why did the psychiatrist decide to hospitalize Carlos?
ANSWER: Even after switching him to setraline (Zoloft), Carlos continued to have problems, such as refusing to go to work and feeling as if he would never “get better.” Dr. Hsu felt that in the hospital a concentrated effort could be made to find an effective medication regimen. (p. 49)
7. What concerns did Sonia, Carlos’ wife, have about her husband’s depression?
ANSWER: Sonia had known Carlos as a strong man who was a good father and caring husband. As his depression advanced, he stopped participating in family activities and he failed to meet his responsibilities on the job. (p. 50)
8. What type of psychotherapy did Dr. Walden use with Carlos?
ANSWER: Dr. Hsu recommended a psychotherapist who specialized in cognitive therapy. Dr. Walden felt that Carlos might be helped by a combination of medication and cognitive therapy that was specifically designed to treat depression. (p. 51)
9. What were the criteria for Carlos’ diagnosis of major depressive disorder?
ANSWER: “He exhibited a depressed mood most of the time, had markedly reduced pleasure or interest in his usual activities, suffered from sleep difficulty, and had lost both his energy and ability to concentrate.” (p. 51)
10. What are some of the “concentrated methods” that must be used in order to rid depressed persons of their cognitive bias?
ANSWER: “The process includes psychoeducation, self-monitoring by clients, self-examination, sustained questioning by therapists, personal research by clients, and retraining in how to think about things. In addition, behavioral methods are typically used to enhance the cognitive techniques.” (p. 52)
11. Carlos wanted to know how long it would be before he felt “normal” again. Why did Dr. Walton not want to give Carlos a definite timetable?
ANSWER: “Dr. Walden wanted to avoid setting up expectations for improvement by specific dates, foreseeing that if expectations were not met, it would fuel Carlos’ negative view of the future.” (p. 52)
12. What was the first “assignment” Carlos was given for the first week of therapy?
ANSWER: Carlos was asked to monitor his emotional reactions throughout the next week, recording all thoughts and events that produced distress (sadness, anger, anxiety, etc.) and rate the intensity of the emotions. (p. 53)
13. Why did Dr. Walton want Carlos on an antidepressant medication as well as the cognitive therapy approach?
ANSWER: (p. 53) Studies suggest that a combination of psychotherapy and drug therapy is modestly more helpful to depressed people than either alone (Frank et al., 2000; Miller et al., 1999).
14. What was the homework assignment given in session # 2? What was the purpose of this assignment?
ANSWER: Carlos was to continue to keep a record of his unpleasant thoughts and emotions, but now he was also to produce alternative, more realistic thoughts. The assignment was given so that Carlos could look at all the evidence (both the unpleasant thoughts and the more realistic interpretation) before reacting to a situation. (p. 55)
15. Why was it important to get Carlos to set up an “evening routine” of activity?
ANSWER: Carlos’ full participation with his family would dispel his perceptions that he was dysfunctional and promote the belief that although he was suffering from depression, he still could function within the family. Also, it would force him into activity rather than using his depression as an excuse to avoid family responsibilities.
16. This case study mentions that about half of depressed clients may experience marital problems. What factors led Sonia to become frustrated with Carlos’ behavior?
ANSWER: (From page 59) “As many as half of all depressed clients may experience marital problems. In such cases, couple therapy may be as helpful as cognitive therapy (Teichman et al., 1995). Carlos had been using his depression to withdraw from many family activities and responsibilities. Sonia was feeling resentful at his lack of participation in family activities and avoiding responsibilities at work. (pp. 49–60)
17. Why is it suggested that clients stay on their medication for several months rather than quitting once they begin to feel better?
ANSWER: (From page 60) “If people who respond to antidepressant medications stop taking the dugs immediately after obtaining relief, they run as much as a 50% risk of relapsing within a year (Montgomery et al., 1993). The risk of relapse decreases considerably if they continue taking the drugs for 5 months or so after being free of depressive symptoms (Kocsis et al., 1995).”
18. How many sessions did it take for Carlos to return to “full-functioning”?
ANSWER: In sessions 10–14, Carlos began to return to full-functioning and stated he was in good spirits most of the time. (p. 61)
CASE 5: BIPOLAR DISORDER—GINA
1. What event prompted Gina’s first symptoms of bipolar disorder? ANSWER: Her first incident occurred at age 17, when Gina participated in a high school play.
2. What events may have turned her mania into depression?
ANSWER: As Gina’s behavior became inappropriate, her classmates began to avoid her. This led her to become paranoid and eventually led her to depression, as she believed everyone “hated her and wished she were dead.” (p. 65)
3. What was the reason for her second hospitalization?
ANSWER: During her sophomore year in college, she spent days in her room developing grandiose plans for space travel after she had taken a course in astronomy. She had stopped attending classes and was sleep deprived, and when she refused to be seen at the student health center, the dean notified Gina’s parents. They recognized her previous behaviors in high school and admitted Gina to a psychiatric hospital.
4. What medications were used in the beginning of her treatment and then several years later to assist in reducing Gina’s symptoms?
ANSWER: When Gina was first hospitalized the antipsychotic drug haloperidol (Haldol) and the antidepressant amitriptyline (Elavil) were given. This combination worked well for a while. Later on in her treatment thioridizine (Mellaril) and lithium carbonate, in combination with chlorpromazine (Thorazine) for sleep, was given. (p. 66)
5. Why did Gina decide to stop taking her medications and what was the result?
ANSWER: Gina felt incapable of staying on medications consistently. Although the drugs removed the manic episodes they made her feel emotionally flat and she longed for “the feeling of being alive.” She became more vulnerable to manic episodes and depression. (p. 66)
6. Which of her manic behaviors became a concern to her parents?
ANSWER: Of particular concern to her parents was her indiscreet sexual behavior. Not only did she develop a sexually transmitted disease, she also had a reputation for being sexually promiscuous. (p. 67)
7. Gina suffered from delusions of grandeur. What was her specific grandiose idea?
ANSWER: Gina was convinced that she had found the ultimate cookie recipe and spent a great deal of money and time involved in this delusional idea. (p. 67)
8. Explain the concept of the “two-physician certificate.” Why was this necessary in Gina’s case?
ANSWER: This procedure allows clinicians to temporarily commit a patient to a psychiatric hospital in an emergency situation. In the past two physicians had to order the patient to be committed. Today, in some states, non-physician mental health professionals may initiate certification. However, it is still called the 2PC. Gina refused to admit herself to the hospital, as she did not feel her behaviors were inappropriate. (p. 68)
9. Why do friendships suffer when an individual is bipolar?
ANSWER: While Gina made friends initially, sooner or later her manic/depressive episodes would eventually prove confusing and frightening to her friends. (pp. 69–70)
10. Genetic studies have linked bipolar with gene abnormalities on which chromosomes?
ANSWER: (From page 71) “Various genetic studies have linked bipolar disorders to possible gene abnormalities on chromosomes 4, 6, 11, 12, 13, 18, 22, and X (Berrettini, 2000).”
11. Why did Gina decide to begin therapy with Dr. Rabb?
ANSWER: A friend of Gina’s had been seeing this psychiatrist for four years and Dr. Rabb had helped him settle down where others had failed. Gina felt as if time was running out for her if she wanted to have a normal life, so agreeing to see Dr. Rabb was worth a try. (p. 71)
12. Why did Dr. Rabb choose the diagnosis of Bipolar I?
ANSWER: Gina had experienced both manic and depressive episodes. Her manic episodes were characterized by grandiose thinking, decreased need for sleep, increased talkativeness, and behaviors that created painful consequences. (p. 72)
13. Why did Dr. Rabb want to increase Gina’s lithium level?
ANSWER: Dr. Rabb felt that Gina’s lithium level was not at a therapeutic level. Since she was already taking the medication, he increased her dose gradually to see if she would demonstrate more therapeutic results from the lithium. Unfortunately, it did not bring about the desired results. (pp. 73–74)
14. What is meant by the term “rapid cycling”?
ANSWER: (From page 75) “If people with bipolar disorder experience four or more mood episodes within a 1-year period, their disorder is further classified as rapid cycling.”
15. Why did Dr. Rabb suggest that Gina see a psychotherapist, Dr. Kohl?
ANSWER: Dr. Rabb felt that Gina might benefit from some psychotherapy as she was having problems with relationships and other issues related to her disorder beyond her medical needs. (pp. 76–77)
16. What type of therapy did Dr. Kohl use with Gina? ANSWER: Dr. Kohl chose to use insight-oriented therapy. (p. 77)
17. How many years did it take for Gina’s moods to stabilize? ANSWER: By the third year of treatment, Gina’s life began to stabilize. (p. 78)
18. What new medication was used to replace the Lithium? What are the advantages of these newer medications over Lithium?
ANSWER: Gina was given valproate (Depakote), a new mood stabilizer. This newer medication gave her back some of the emotional richness she was missing without the increased risk of bipolar episodes returning. (p. 79)