Case studies in non evidence based treatment Part one-1 UAGC

UAGC | Case studies in non evidence based treatment Part one-1 UAGC

Hello, and welcome to this discussion. My name is Dr. Steven Brewer, and this is the first of two audio files that will introduce case studies in non evidence based treatment. But first, what is evidence based treatment? Evidence based treatments, or evidence based practices, are generally those that are supported by peer reviewed scientific literature.

This definition may lead you to assume that non evidence based practices are those that have been disproven by peer reviewed scientific literature, but that isn't the case. Non evidence based practices are simply those practices that have not been supported by peer reviewed literature yet. Joining me to talk more about non evidence based practices is Dr. Erick Cervantes, Assistant Professor and Chair of the Complementary and Alternative Health Program at Ashford University. He'll be sharing with us some fascinating cases where evidence based practices fail to completely help a patient's concerns.

Thank you Dr. Brewer. I appreciate this time. A little bit of background first, I have a relative by the name of Ivan S., and so Ivan is a Navajo descent individual born in the area of the Navajo reservation in Arizona. And in his early years, between the age of 20- years-old and 26-years-old, he was deployed to Iraq for a couple of tours in that war. In any event, the point is that the first time they returned from that war, Ivan came back with a lot of anger management issues at home and began to have a lot of squabbles with his wife and children, which was very different than what he was before.

He did another tour thereafter. Of course, there were other problems in the household prior to his next departure, but when he returned it was very apparent that he was very much affected by the war. He was taken to the Naval hospital here in Southern California. His mood became stoic, but his behavior continued to be very, very aggressive.

He began to beat his wife, began to beat his children, recurrent nightmares at night, night sweats, and many, many, many problems. And he continued on to go into the Naval hospital with no– here in Southern California with no apparent relief of his symptoms or his behavior. He began to drink, began to have issues with the law, and so to no– again, no rescue from conventional practice with the medications and the treatment. He began to also go to see a counselor, but that also didn't do very well.

OK so, a little bit of background on what we'll call patient M.D., so at a very– she grew up, basically, in a very poor town, a agricultural town of many, many migrants. Migrants of Mexican descent as well as Central American descent. Mother and father married at an early age. Probably, I think there was seven children in her family, if I remember correctly of this case, and she was one of the younger females of the family.

At that time and at this place, there were rival gangs that were part of her life, but as she began to go into her teenage years, she began to experience a lot of attention from a lot of her male peers. But one time, at one point, she began to have problems with these peers that were gang related, and then experienced gang rape from the age of 14 to 16. She belonged, actually, to one of the rival gangs, so therefore, it was very apparent that her collusion or her involvement with the rival gang brought her into more at risk for these things to happen.

Not that– not as a justification, but more of how these gangs relate to each other. She began to– then from that point, after 16, she began to use more heavily both marijuana, meth, heroin, alcohol, and she expressed that, more than anything, she was trying to drown out the anxiety, the fear, the panic attacks that she would experience on an everyday basis due to her belief that this would happen again at any time soon. She at the age of 18, she disbanded from these gangs and began to have her own life, trying to go to school, finish high school specifically.

She finished with the GED and was in and out of college between the ages of 19 and 24. And her family life, she dissociated completely from her mother and father because she felt that she felt abandoned by them, specifically when she was trying to address the trauma that she experiences so young. As a matter of fact, she even expressed to them that she was raped and that she wanted some people to go to jail for it, but the parents did not proceed to help her out with any legal ramifications that would come from that.

So she felt also disregarded, especially for what she wanted to do. Her parents actually blamed her for the rape, so she carries a lot of rancor and a lot of anger towards her parents and manifest that in many ways towards her parents. She's disrespectful. She reports that she's very disrespectful. She doesn't really visit them that often, she has a lot of fights with them for many, many little things.

She's been in and out of relationships, very short term relationships. Mostly been intimate relationships, rather than more of a whole relationships with peers, specifically male peers. She identifies as bisexual, but she prefers men, but still has a lot of issues with men and constantly fights with men, physically fights with men and especially her partners.

Socially, now her focus is she's an activist. She does a lot of work with migrant families trying to educate them, trying to empower them. She also goes to rallies too for migrant rights and also undocumented rights, so she is very much like a social worker, as well as an activist, and believes that she's doing this because she, you know, she's trying to give back for people that are also abused and disregarded in this society.

She is very youth oriented, so she's– a lot of her focus is educating youth and also preventing youth violence, specifically sexual violence against youth and especially females. However though, on the other side of the spectrum, she's so ardently a zealot, actually, with these ways of being because she can't take no for an answer. She does things by force, so in essence she encompasses a very strong male, almost patriarchal attitude about things and she demands things to be done in a certain way, which hampers a lot of her relationships with people. She can't really form very good social bonds and really alienates a lot of people with her force or with the way that she is in forcefully pushing her agenda on folks and forcefully pushing a lot of her– yeah, mostly her agenda of helping youth, et cetera.

So I guess what I'm saying is that there definitely would be a better balance if she was a little more in tune with how she manifests to people. Right now, you know, she would probably have more allies if she wasn't so harsh in manifesting what her agenda is. Again, as previously said, I said she suffers a lot from anxiety, she suffers from insomnia, she currently takes medication for anxiety, and she continues to self-medicate with marijuana to also decrease the anxiety. She has some social phobia, but also very outgoing, interesting enough, so she has both of those polarities, and suffers from panic attacks on a constant basis.

Really even more interesting from a kind of holistic way of looking at this is that she was recently diagnosed with uterine cancer, and what that does from my perspective as a clinician and naturopathic doctor, what that tells me is that the energetic imprint of that trauma obviously is well imprinted in the uterus, and the manifestation of that trauma is still there. So if she goes on to do other work, specifically spiritual work or other forms of therapy, I think there's a possibility to lift that cancer growth. And not from a chemical perspective, you know, not from chemotherapy or radiation therapy, but more from a very intuitive, very mental, emotional, and spiritual practice, so other recommendations will be given from that. So that's the background on M.D.

Well, thank you Dr. Cervantes for that fascinating case study. Students your challenge as individuals looking at these cases is to provide a provisional diagnosis for these patients, and then propose the treatments as discussed in the discussion forum.

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This is a graded discussion: 6 points possible due Oct 27 at 1:59am

Week 5 – Discussion 16

Your initial discussion thread is due on Day 3 (Thursday) and you have until Day 7 (Monday) to respond to your classmates. Your grade will reflect both the quality of your initial post and the depth of your responses. Refer to the Discussion Forum Grading Rubric under the Settings icon above for guidance on how your discussion will be evaluated.

Evidence and Non-Evidence Based Treatment Options

Prior to beginning work on this discussion, please read both “Limitations to Evidence- Based Practice” and “Rationale and Standards of Evidence-Based Practice,”and listen to the Case Studies in Non-evidence Based Treatment Part One (https://uagc.instructure.com/media_objects_iframe/m-vuF2rwbgQ1sTCR8iXfSZCotQSrxbecW? type=audio) (if needed transcript (https://uagc.instructure.com/courses/123214/files/20485069?wrap=1) (https://uagc.instructure.com/courses/123214/files/20485069/download?download_frd=1) for part one audio). On the last day of Week 5, listen to Case Studies in Non-evidence Based Treatment Part Two (https://uagc.instructure.com/media_objects_iframe/m- 2zVXhBhECeVabUGt8mJq4C7CzUjrJD62?type=audio) (if needed transcript (https://uagc.instructure.com/courses/123214/files/20485088?wrap=1) (https://uagc.instructure.com/courses/123214/files/20485088/download?download_frd=1) for part two audio).

For your initial post, you will choose one of the case studies from this week’s audio file selection on which to base your remarks. Based on the available information, evaluate the symptoms and presenting problems for the patient in the chosen case study and propose a provisional diagnosis. Describe one evidence-based treatment for this diagnosis and provide a rationale for your choice. Research at least two peer-reviewed articles to support your evidence-based treatment selection.

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Guided Response: Review several of your colleagues’ posts, and respond to at least two of your peers by 11:59 p.m. on Day 7 of the week. You are encouraged to post your required replies earlier in the week to promote more meaningful interactive discourse in this discussion.

Examine your colleague’s initial post, and assume the proposed evidence-based treatment was ineffective. Using a sociocultural perspective, provide an explanation for why the evidence-based treatment may have been ineffective in this case. Describe at least one non-evidence-based treatment option as an alternative to evidence-based treatment in this case. Compare and contrast the failed evidence-based treatment with the proposed non- evidence-based treatment option. Justify the use of the proposed non-evidence-based treatment option for this patient (i.e., How does this treatment option meet the patient’s unique sociocultural needs?).

Continue to monitor the discussion forum until 5:00 p.m. Mountain Standard Time (MST) on Day 7 of the week, and respond to anyone who replies to your initial post. Be sure to indicate whether your diagnosis and conceptualization has changed based on your colleague’s feedback.

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(https://uagc.instructure.com/courses/123214/users/122746)Trennan Perez (https://uagc.instructure.com/courses/123214/users/122746) Wednesday

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Based on the information provided, it appears that the patient, whom we'll refer to as M.D., is dealing with a complex set of symptoms and presenting problems that may warrant a provisional diagnosis of Post-Traumatic Stress Disorder (PTSD). Here's a breakdown of the symptoms and presenting problems that align with this diagnosis.

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Traumatic Events: M.D. has a history of experiencing severe traumatic events, including gang rape during her teenage years. These traumatic experiences have had a lasting impact on her.

Avoidance and Anxiety: She describes trying to cope with overwhelming anxiety and fear stemming from the trauma, which leads to panic attacks. Her extensive use of substances like marijuana, meth, heroin, and alcohol is an attempt to self-medicate and manage her anxiety.

Dissociation and Relationship Issues: M.D. has distanced herself from her family, particularly her parents, due to feelings of abandonment and anger toward them. She reports disrespectful behavior and frequent fights, especially with men, which suggests difficulties in forming and maintaining relationships.

Activism and Zealotry: M.D. has become highly involved in activism, focusing on supporting marginalized communities and addressing issues of abuse. However, her approach is forceful and demanding, which can alienate people and hinder her social relationships.

Medical Diagnosis: The recent diagnosis of uterine cancer may indicate a connection between her past traumas and the manifestation of physical health issues, possibly due to the unresolved emotional and psychological impact.

Given the trauma, anxiety, avoidance behavior, and the impact of her experiences on various aspects of her life, a provisional diagnosis of PTSD seems appropriate.

Evidence-Based Treatment: The primary evidence-based treatment for PTSD is Cognitive-Behavioral Therapy (CBT), specifically Trauma-Focused CBT. This therapy helps individuals address and reprocess traumatic memories and manage anxiety and avoidance behaviors. M.D. could benefit from CBT to work through her traumatic experiences, reduce her anxiety and panic attacks, and develop healthier coping strategies.

Rationale: Trauma-Focused CBT has a strong evidence base for treating PTSD. It involves exposure therapy, cognitive restructuring, and the development of healthy coping mechanisms. Given M.D.'s history of trauma, anxiety, and avoidance behaviors, this therapy can provide her with the necessary tools to process her traumatic experiences and work toward healing. It's essential to approach this case with sensitivity and consider the physical health aspect as well. A comprehensive

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with sensitivity and consider the physical health aspect as well. A comprehensive treatment plan might involve a combination of therapies, potentially including holistic approaches, to address the psychological and emotional aspects of her health concerns.

References

Brewer, S., Cervantes, E., & Simpelo, V. (2014). Case studies in non-evidence- based treatment: Part one (https://uagc.instructure.com/media_objects_iframe/m- vuF2rwbgQ1sTCR8iXfSZCotQSrxbecW?type=audio) [Audio]. Canvas@UAGC. https://login.uagc.edu

Chung, M. C., & Hyland, M. E. (2012). History of clinical psychology and philosophy of mental health (https://uagc.instructure.com/courses/123214/files/20485091?wrap=1) (https://uagc.instructure.com/courses/123214/files/20485091/download) . In History and philosophy of psychology. John Wiley & Sons.

Maier, T. (2012). Limitations to evidence-based practice (https://ebookcentral.proquest.com/lib/ashford-ebooks/reader.action? docID=817356&ppg=77) . In P. Sturmey & M. Hersen (Series Eds.). Handbook of evidence-based practice in clinical psychology: Vol. 2. Adult disorders (pp. 55-69). Hoboken, N.J.: John Wiley & Sons.

Mudford, O. C., McNeill, R., Walton, L., & Phillips, K. J. (2012). Rationale and standards of evidence-based practice (https://ebookcentral.proquest.com/lib/ashford-ebooks/reader.action? docID=817355&ppg=27) . In P. Sturmey & M. Hersen (Series Eds.), Handbook of evidence-based practice in clinical psychology: Vol. 1. Child and adolescent disorders (pp. 3-26). Hoboken, N.J.: John Wiley & Sons.

(https://uagc.instructure.com/courses/123214/users/356487)Michelle Ybarra CLICK TO EXPAND / COLLAPSE

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(https://uagc.instructure.com/courses/123214/users/356487) Thursday

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Hi Trennan,

Great job on your post.

When you stated, “The primary evidence-based treatment for PTSD is Cognitive- Behavioral Therapy (CBT), specifically Trauma-Focused CBT. This therapy helps individuals address and reprocess traumatic memories and manage anxiety and avoidance behaviors”. I agree with your statement. M.D. might benefit from cognitive behavioral therapy (CBT) to process her traumatic experiences, lessen her panic episodes and anxiety, and create healthy coping mechanisms. There is substantial evidence to support the use of trauma-focused cognitive behavioral therapy (CBT) in the treatment of PTSD. It entails cognitive restructuring, exposure treatment, and the creation of constructive coping strategies. This treatment can provide M.D. the tools she needs to process her traumatic experiences and strive toward recovery, given her history of trauma, anxiety, and avoidance habits. It is imperative that we handle this issue delicately and take into account the physical health component as well. To treat the psychological and emotional components of her health issues, a thorough treatment plan may include a variety of therapies, maybe even holistic ones. You provided great information on M.D. as well as breaking down the symptoms and presenting problems that align with this diagnosis.

My best,

Michelle Y.

(https://uagc.instructure.com/courses/123214/users/5168)Irene Kovacs-Donaghy (https://uagc.instructure.com/courses/123214/users/5168) Yesterday

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Hello Trennan

Good info, trauma focused CBT can be powerful. if you were to select a second source to support this evidenced based treatment, what would it be? What other articles are out there?

Dr.K

(https://uagc.instructure.com/courses/123214/users/338520)Kenneth Brown III (https://uagc.instructure.com/courses/123214/users/338520) Wednesday

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Hello class,

Ivan S. exhibits various symptoms and presenting problems, including severe anger management issues following his deployments to Iraq, marked by physical violence towards his family. His mood transitioned to stoicism, potentially indicating emotional numbing linked to traumatic experiences. Recurrent nightmares and night sweats strongly suggest post-traumatic stress. Ivan also turned to alcohol, experienced legal troubles, and conventional treatments, including counseling, failed to alleviate his symptoms or address the root causes of his distress (Brewer et al., 2014). These symptoms and problems collectively suggest a provisional diagnosis of Post- Traumatic Stress Disorder (PTSD), with the need for an evidence-based treatment approach such as Prolonged Exposure Therapy (PE) to effectively address the core symptoms and the underlying trauma.

The provisional diagnosis for Ivan S. is Post-Traumatic Stress Disorder (PTSD). His presentation of severe anger management issues, mood shifts towards stoicism, recurrent nightmares, night sweats, and aggressive behavior following his Iraq deployment indicates trauma-related distress. Conventional treatments have proven ineffective in alleviating his symptoms and addressing the root causes of his

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ineffective in alleviating his symptoms and addressing the root causes of his emotional turmoil. Given this diagnosis, an evidence-based treatment approach such as Prolonged Exposure Therapy (PE) is recommended. PE is a form of Cognitive- Behavioral Therapy (CBT) that explicitly targets PTSD, increasing the perception of social support (Bourassa et al., 2020). It can effectively address Ivan's symptoms by focusing on processing traumatic memories, cognitive restructuring, and evidence- based success, making it a well-suited choice for his unique situation, particularly given his military background and exposure to trauma. Comparing PE to traumatic and non-traumatic exposure methods, PE significantly affected samples taken to reduce PTSD symptoms and active periods (McLean et al., 2022).

Thank you,

Kenny

References

Bourassa, K. J., Smolenski, D. J., Edwards-Stewart, A., Campbell, S. B., Reger, G. M., & Norr, A. M. (2020). The impact of prolonged exposure therapy on social support and PTSD symptoms. Journal of Affective Disorders, 260, 410–417. https://doi.org/10.1016/j.jad.2019.09.036 (https://doi.org/10.1016/j.jad.2019.09.036)

Brewer, S., Cervantes, E., & Simpelo, V. (2014). Case studies in non-evidence-based treatment: Part one [Audio]. Canvas@UAGC. https://login.uagc.edu

McLean, C. P., Levy, H. C., Miller, M. L., & Tolin, D. F. (2022). Exposure therapy for PTSD in military populations: A systematic review and meta-analysis of randomized clinical trials. Journal of anxiety disorders, 90, 102607. https://doi.org/10.1016/j.janxdis.2022.102607

(https://uagc.instructure.com/courses/123214/users/266156)Adam Henning (https://uagc.instructure.com/courses/123214/users/266156) Thursday

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Hello Kenneth,

I agree that Ivan S. has a variety of signs, symptoms, and challenges, notably serious problems with controlling his anger as a result of his tours in Iraq. His demeanor actually shifted to stoicism, maybe reflecting a detachment caused by the painful events that he had to endure. Also, Ivan also became addicted to alcohol and had legal problems, and traditional therapies failed to relieve his symptoms or address the underlying reasons for his unhappiness. With this case study, in particular, I definitely agree that Ivan has PTSD.

My question is could his PTSD be complex, acute stress disorder, uncomplicated PTSD, or comorbid PTSD? I feel there's potentially a strong case for each variation of PTSD. However, pinpointing the specificity and potential comorbidities via assessments, etc will be the key to narrowing down the exact diagnosis. I also agree that one of the best courses of action in combating PTSD is the implementation of CBT. Overall, Kenneth, you have done an outstanding job on this discussion.

Respectfully,

-Adam h

(https://uagc.instructure.com/courses/123214/users/266156)Adam Henning (https://uagc.instructure.com/courses/123214/users/266156) Wednesday

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Hello Classmates and Dr. K,

The patient, who we'll call M.D., seems to be experiencing a complicated range of manifestations along with symptoms that would support a preliminary diagnosis of the dissociative subtype of PTSD based on the evidence supplied. Below, is my

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