0:33 Video trnascript
the reference to this article in the
description for this video this is an
interesting presentation example it’s of
an eight-year-old boy I’ll call him Joe
this takes place in the United Kingdom
this is a good example of how a
traumatic event might not seem severe
but how it’s the interpretation that can
lead to post-traumatic stress disorder
it’s also a good example of how trauma
focused cognitive therapy can be used to
treat post-traumatic stress disorder one
of the mysteries of post-traumatic
stress disorder is why does it tend to
form in some people who have relatively
minor of
massacre when it might not form and
other people have really serious events
occur right so for example a severe
motor vehicle accident compared to a
minor motor vehicle accident and that’s
what we’re talking about here in this
case a minor motor vehicle accident well
we learn here of course is it’s not just
the severity of the traumatic event that
matters there are a number of other
factors that have to be weighed in
genetic factors environmental factors
prior experiences cognitive processing
and what was perceived during the event
so first I’ll review Joe’s history then
take a look at trauma focused cognitive
therapy and then look at the course of
treatment in this case so again Joe is 8
years old he lives with his father and
two older siblings Joe’s father takes
care of the three children alone as his
wife left him many years ago Joe’s
father has a physical disability but no
history of mental health conditions now
taking a look specifically at the
traumatic event I mentioned it was a
minor motor vehicle accident we see that
Joe was riding home as a passenger in
the front seat of his father’s car his
father was driving they were coming back
from soccer practice and his father
entered into a traffic circle in this
case it was a five-way intersection the
father slows down as he sees another
vehicle in the circle so he has to yield
to that vehicle because either the
vehicle has the right of way
and as the father slows down the vehicle
behind him runs into the rear of his
vehicle the guy behind him was driving
too fast not paying attention whatever
was going on there but again he drove
into Joe’s father’s car so Joe was not
hurt at all Joe’s father sustained a
minor injury to his knee because it hit
the steering column there was no airbag
deployment the vehicle is only
cosmetically damaged and it was drivable
immediately after the collision
evidently when Joe’s father exited the
vehicle to talk to the driver that hit
them an argument ensued and the other
driver threatened Joe’s father with
physical harm so Joe’s father got back
into the vehicle and drove away from the
scene but the other driver pursued them
before eventually breaking off the
pursuit by pulling over on
the road Joe’s father waited till they
arrived home before he called the police
shortly after this event Joe was taken
in to receive mental health care he
presented with intrusive memories of the
accident and the subsequent pursuit he
did not seem to understand the incent
but he did understand that was an
accident
and the car was slightly damaged and he
also understood that the other driver
chased him and his father Joe we become
very anxious when presented with
anything that reminded him of the
accident the stretcher Road word
occurred stories on television related
to car accidents the type of vehicle
that hit them and talking about the
insect Joe had trouble sleeping it took
him a few hours to get to sleep and had
to go to sleep in the same room as his
dad to fall asleep he also had a lot of
nightmares
he became physically aggressive in
school and at home at school he was
engaging in outburst in the middle of
class it was one incident where he
turned over tables and threw trash all
around the classroom and apparently this
was pretty frightening to the school
staff and to his fellow students at home
he was fighting with older siblings and
was set off by the slightest
provocations in addition to meeting the
criteria for post-traumatic stress
disorder Joe had significant comorbidity
including oppositional defiant disorder
conduct disorder that’s really uncommon
that both of those diagnoses would be
givens he also had major depressive
disorder attention deficit hyperactivity
disorder ADHD separation anxiety
disorder and one specific phobia spiders
the only diagnoses that were of concern
before the incident would be the ADHD
and the fear of spiders all the other
diagnoses were given after the event
that’s a lot of mental disorders to be
diagnosed with that quickly I’ll talk
about this a little later specifically
at the post traumatic stress disorder we
see Joe had symptoms of hyper or
avoidance and intrusive thoughts he also
had a disorganized understanding of the
event and didn’t really seem to be able
to discuss the incident so now take a
look at the trauma focused cognitive
therapy a key concept of this therapy
when talking about PTSD
is the nature of the traumatic memory
not so much what happened but again the
properties of the actual memory it’s
considered to be critical to the
development of PTSD individuals with
PTSD often struggle to retrieve
information about the event when they do
recall information it’s often fragmented
and disorganized as I mentioned this is
something of course we see specifically
in this case with Joe another important
concept is the idea of maladaptive
appraisals so an individual PTSD is
unable to accurately assess the event
and the idea that the event was time
limited so they don’t really understand
that the event is in the past but it’s
over this leads to the sense that
there’s some sort of current threat
right again so the traumatic event is
not just in the past but it’s happening
right now in some way or it may happen
right now in some way to address these
concepts and the other factors we see
around PTSD trauma focused cognitive
therapy focuses on the 3ms of PTSD
memories
distorted memory representations
meanings the maladaptive cognitive
appraisals and management this is
working on the difficulty we see with
coping with feelings and thoughts and
perceptions so now moving to the course
of treatment we see in this case of Joe
the treatment team explained to Joe how
the treatment was supposed to work so
they explained the three M’s and all the
other information about trauma focused
cognitive therapy we see that Joe’s
father joined him for the early sessions
this kind of makes the client more
comfortable in the case of Joe it
certainly did these initial sessions had
a lot of normalizing of the response to
the event so anybody would be distressed
if they are in a car accident and
pursued by the person that hit them
there was a lot of rapport building they
made it clear to Joe that he had
permission to talk about the event which
I think seems particularly bored in this
case because again he had difficulty
really expressing thoughts or feelings
around the incident they also gave him
permission to talk about the symptoms
and they discussed the incident in a
calm and safe way kind of setting at
for joe tafolla trying to really make
This a little bit less emotional for Joe
Joe was encouraged to recognize his
emotions to express his emotions and to
manage the more extreme emotional
reactions some relaxation techniques
were used including progressive muscle
relaxation Joe was also instructed to
practice this at home so we see some
homework assigned which is actually
fairly common for all different types of
cognitive therapy we see the specific
cognitive distortion was identified
early on this is that Joe believed that
the world was a different place since
the accent in relation to him right so
he didn’t fit in with the world in the
same way because of that accent
Joe was assigned a number of new
activities this is called behavioral
activation essentially we see a series
of tasks that Joe and his father would
complete together for example they would
play soccer in the garden then in the
street and then play soccer in the park
the idea here was they’re trying to move
Joe into other geographic areas and
increased the probability of contact
with his friends from these behavioral
activation exercises it became clear
that one of Joe’s fears was that when he
was away from his father something bad
would happen to his father to alleviate
this fear they discussed with Joe how
his father – actually been a number of
altercations before this incident they
tried to sell this like Joe’s father had
a lot of skill at surviving fights so it
always worked out okay for him because
he knew how to take care of himself I’m
not sure I would have gone with this
route right like telling Joe that his
father had been in a lot of fights and
kind of was a survivor it seems a little
unusual to me it’s kind of introducing
new information that may have backfired
but we see in the case report that this
appears to have been effective again
maybe not something I would have done
but a kind of maneuver that seemed to
work in this case Joe also incorrectly
believed that his father was still
suffering from the injuries that
occurred in the accent what we see is
that Joe became more alert about
behavior as his father already engaged
in for example taking medication the
father already did this right
early but now Joan noticed it and
attributed this behavior to the accent
so Joe had a lot of blanks in terms of
understanding what happened and he
tended to fill in those blanks with the
worst case scenario the treatment team
kind of created a game for Joe to
address this making him the detective
who is responsible to find evidence and
fill in those blanks so unlike that
other technique of talking about all
these flights that the father had been
in I think this technique makes a lot of
sense
this one really I think kind of empowers
Joe and allows him to use his creativity
and critical thinking skills to solve
problems that could help him move past
these symptoms so I really like this
technique in particular we see an
example of some of the blanks that Joe
had in terms of the narrative Joe
believed that immediately after the
accent that him and his father were both
severely injured so severely in fact he
believed they required immediate medical
treatment because they did not receive
treatment Joe felt that there must be
unresolved physical issues so he
believed that both him and his father
had physical problems as a result of
that accent but really it was a
cognitive distortion they did not have
any problems at the time that Joe was
receiving treatment so to address this
they talked with Joe about his
understanding what happened and in the
narrative we see that behind the vehicle
that hit Joe and his father there was an
ambulance the ambulance crew saw the
accident of course they were right
behind the vehicle to hit him as I
mentioned but then they drove past the
accent drove around the circle and came
back to make sure that no one was
injured to the degree where they would
need transportation to the hospital Joe
remembers seeing the ambulance twice
which is in fact what happened the
ambulance passed their position again
two times going past them and then
coming back the presence of that
ambulance led to this assumption by Joe
that he would need to be hospitalized
therefore his injuries must have been
serious so again we kind of see how
these cognitive sources play out there
was information that was accurately
collected at the time by Joe but
incorrectly interpreted
the treatment team was able to spin this
around and paint another narrative I
thought this was also a good technique
they said clearly it was unlikely that
Joe and his father were severely injured
as evidenced by the ambulance crew
seeing them and continuing on so they
really took the same information but
interpreted more accurately and in a way
tat was more helpful to treating Joe’s
symptoms Joe made fairly good progress
as a result of therapy
there was this distress scale that they
used in therapy and went from 0 to 10
with 10 being the most distressed Joe
initially reported a score of 10 when
discussing the incident but by the time
he got to the end of therapy he was
reporting scores of 0 during all parts
of his narrative not just the parts
associated low distress but even the
parts that have been associated with a
high l
presentation example this is an
interesting case we get to see as I
mentioned before how severity may be
important sometimes but it may not be
the most important thing for everybody
and it would also appear here that the
altercation was as traumatic as the
accent so I think that’s what’s really
interesting about this as well we see
this accent that was fairly minor right
Joe was uninjured but then we see this
pursuit and that as a separate incident
could be quite frightening and it’s
really again how somebody perceives that
pursuit I think most people would have
been fairly alarmed when being chased by
another car but by the accident itself I
think most people would not have viewed
that as traumatic when these things
combined for Joe it did result again in
the development of post-traumatic stress
disorder
we’re also left with the sense that if
Joe didn’t realize that they were being
chased he would not have been
traumatized right so maybe the motor
vehicle accident really wasn’t enough to
lead to PTSD but it was his
interpretation of that pursuit which of
course as I mentioned would have been
scary to anybody but if he was sitting
there and didn’t know about it he may
not have had any reaction to it now
there’s not a strategy that comes from
this of course there’s no way to really
say hey let’s ignore what’s going on
right Joe’s father couldn’t have just
said hey nothing’s really happening here
not worry about it he had to acknowledge
what was going on and he was probably
scared himself but again it just points
back to how important perception is I
mentioned before that it seemed like Jo
was given a large number of diagnosis I
have to in some sense of course defer to
the people that treated him because they
actually saw him and they put together
this case report but I can’t help
thinking that it may have been more
useful to diagnose him just with
post-traumatic stress disorder and treat
that for a while
rather than stacking on a lot of
diagnoses the one that concerns me the
most of course is that conduct disorder
diagnosis conduct disorder carries a
stigma because about a third of
individuals diagnosed with it will go on
to develop antisocial personality so I
think I would have tried to avoid the
conduct disorder diagnosis especially
because the oppositional defiant
disorder was already diagnosed as I
mentioned before it’s unusual to have
both of those diagnoses together usually
it’s just one or the other of course
somebody can technically be diagnosed
with both but again this is somewhat
unusual and if you have the o DD
diagnosis there I don’t really see the
urgency to go ahead and move forward
with conduct disorder but again that’s
just my opinion for me in the case
report there’s a lot of information of
course that would not be included there
of less concern but still somewhat
troubling is the diagnosis of major
depressive disorder this is an episodic
disorder that has a distinct course to
it somebody has a major depressive
episode then they usually recover some
degree and sometime later they have
another major depressive episode usually
sometimes there’s one episode but
usually there’s more than one so this
isn’t something that we really think of
as being associated with a traumatic
event like a traumatic event occurs and
then immediately after that we see major
depressive disorder this is a disorder
where you would typically take a lot of
time before making the diagnosis watch
somebody for a while see if there’s some
sort of change in their mood look at the
level of depression and the level of
some of the other symptoms associate the
disorder so a little bit unusual I think
to jump right to major depressive
disorder as well so we see kind of I
think some unusual diagnostic behave
on the part of the clinicians not
necessarily technically incorrect but
just unusual I thought this presentation
example overall though was excellent and
demonstrating how trauma focused
cognitive therapy could be applied to a
real-life situation and how cognitive
distortions were highly problematic for
Joe and addressing those distortions
seemed to lead to a market improvement
PTSD and part is driven by individual
perceptions it’s what people think of
those events that really matters at
least in some cases so I know whenever I
talk about topics like this like
post-traumatic stress disorder and I
look at these different presentation
examples there gonna be a variety of
opinions please put any opinions and
thoughts in the comment section
they always generate a really
interesting dialogue as always I hope
you found this presentation example on
post-traumatic stress disorder and
trauma focused cognitive therapy to be
interesting thanks for watching