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Journal of Depression and Therapy

Current Issue Volume No: 1 Issue No: 2

Cognitive Behavior Therapy in The School Setting: A Case Study of A Nine Year Old Anxious Boy with Extreme Blushing

Francine c. jellesma  1  .

1 Research Institute Child Development and Education

Within the field of school psychology there is a gap between research and practice, caused by difficulties in translating the programs from research to the realities of the school setting. Illustrations of real-life cases may help school psychologists gain insight into the application of interventions. The purpose of this study was to describe an example of small group cognitive behavior therapy in the school setting. It concerned test anxiety with extreme blushing. A single subject case study of a nine year old Dutch boy was described. Interviews, observations and questionnaires were used for evaluation, as well as a standard national achievement test. The results indicate that the test anxiety and blushing decreased and on the achievement test three years later, performance was good.  As it concerns a case study, the results are discussed tentatively. It was concluded that the intervention was successful without alterations to the program. This study provides an illustration of research put into practice.

Author Contributions

Academic Editor: Addo Boafo, Royal Institute of mental health research

Checked for plagiarism: Yes

Review by: Single-blind

Copyright ©  2017 Francine C.Jellesma,et al.

The authors have declared that no competing interests exist.

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Introduction

This article describes a successful intervention for a nine year old boy presenting emerging test anxiety and extreme blushing. The treatment consisted of a group-based cognitive therapy (CBT) in the school setting. This case-study illustrates how CBT can be applied within primary school addressing test anxiety when the concern is not only on the level of an emerging mental health problem, but also on a specific symptom. Mental health problems are a major concern in primary education because they negatively affect socio-emotional as well as academic school functioning. Within the ecological context perspective of Bronfenbrenner schools represent a key component of the child’s microsystem: they are one of the most proximal influences on a child, and understandably, represent the primary setting where children show impairment due to mental health problems 1 . Research demonstrates that school-based cognitive-behavioral interventions that focus on small groups or individual students yield improvements in emotional, behavioral, social, and academic functioning 2 . Nevertheless, within the field of school psychology there is a gap between research and practice that seems to be caused by difficulties in translating the programs from research to the realities of the school setting 3 . Illustrations of real-life cases may help school psychologists gain insight into the application of interventions.

Test anxiety refers to feeling tense, fearful, and worried in evaluative situations 4 . It has formally been defined by Dusek as an “unpleasant feeling or emotional state that has physiological and behavioral concomitants and that is experienced in formal testing or other evaluative situations” (p.88) 5 . It has been estimated that between 10% to 40% of all students suffer from various levels of test anxiety 6 . In the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR; 7 ), test anxiety is included indirectly as: “Individuals with Social Phobia often underachieve in school due to test anxiety(…)”. Bögels et al. argue that pervasive test anxiety is a form of social phobia (or social anxiety disorder), if fear of negative evaluation by others is the core issue, as was true for the current case 8 . Test anxiety poses students at risk for underperformance on achievement tests, poor grades, repeating a grade and school drop-out 9 , 10 , 11 , 12 . As such, it is important for schools to reduce test anxiety in their students effectively 13 .

Blushing can be one of the symptoms of test anxiety 7 . According to the communicative account of blushing, blushing has a remedial function. It communicates to observers that one is sensitive to their judgment 14 . Experimental research shows that blushing causes others to make more favorable appraisals. A blushing person is considered to be more trustworthy, less responsible for violating a norm and more friendly compared to a person that does not blush, but for example only shows shame 15 . Despite these positive effects, blushing is involuntary and uncontrollable and signals to others the presence of emotions that a person perhaps would like to suppress. The social blushing theory states that blushing occurs when a person receives undesired social attention 16 . Particularly in young people, blushing is a bodily symptom that can occur in situations of increased self-consciousness 17 , and these situations are common for children with test anxiety. Further, it is important to note that blushing is not only an especially salient physiological reaction (feeling warm cheeks), it is also clearly observable to others. As blushing often occurs in situations where one would rather not increase the attention of others, blushing can be highly aversive and for anxious individuals it can become a source of shame and anxiety in its own right 18 .

In the case presented in this article, a nine year old boy was referred to the school psychologist because the teacher noticed that his learning was impaired by a fear of failure. Whereas the teacher felt it was important for him to be able to concentrate on learning; the boy and his family concentrated on the experienced worries, fears, nervousness and extreme blushing. In other words, the important outcomes were: reduction of test anxiety, blushing and the more indirect outcome of school achievement. An important question of the case study was whether the blushing would be reduced by a CBT that was focused on test anxiety. This was the expectation because, not only is CBT one of the interventions that is recommended for treating test anxiety 13 , 19 ; Drummond and Su argue that anxiety management strategies in clinical settings reduce fear of blushing and blushing itself 20 . They demonstrated that social anxiety rather than expected or perceived blushing can increase facial blood flow during embarrassment. Therefore, reduction of anxiety should also lead to subsiding of the blushing.

Importance of this Study

In general, case studies are important because they help make something being discussed more realistic for teachers, school boards, and others. Case studies help people to see that what they have learned or read about a subject is not purely theoretical but instead can serve to create practical solutions to real dilemmas. With respect to interventions in schools, there is discussion about the use of existing programs because people sometimes reason that those problems are unlikely to be successful for a specific case or child 3 . The thought is that the child is an individual that in some aspects departs from the population of children for which the program was developed. Protocols and programs are seen as cookie-cutter approaches that in practice are unfit. With the current study, an example of a program put into practice for a specific child that departs from peers with test anxiety because of the extreme blushing, provides a clear example that CBT can be followed effectively and can meet specific individual needs.

Case Representation

Tim was a nine year old boy from a two-parent family of average social economic status. He lived with his parents and younger brother near his school in a small town in the Netherlands. Tim had entered school at age 4, which is common in the Netherlands where kindergarten and primary school are integrated.

Referral Information

The fourth grade teacher referred Tim to the care coordinator (CC) of the school because she noticed that he displayed clear signs of distress (frequent, visible blushing and expressions of worry) and that his learning progress was unexpectedly low. The CC discussed the referral with Tim’s parents who confirmed that Tim seemed to be bothered a lot by fear of failure and associated distress. The parents agreed for Tim to be seen by the school psychologist (i.e., author of the paper). In order to remain objectively, all assessments and observations were discussed with a second person, a social worker, who also co-observed the second last session of the therapy.

Tim and his parents were interviewed separately from each other using a semi-structured interview. Tim explained that he was very nervous at school before and during tests, and when speaking in front of the class or several classmates. His major concern was that he blushed frequently. According to Tim: “It happens all the time and I get really embarrassed”. Tim said that he would like to show more initiative in certain situations, such as playing a game, but that his shyness and nervousness withheld him from doing so. With concern to his school work, Tim often felt unable to concentrate and had many worries (“I think I will fail”, “I feel uncertain about the task”, “I think I might not be smart enough”).

Tim’s parents showed great involvement and his mother recognized some of the anxiety symptoms from her own youth. The parents confirmed that Tim was bothered frequently by his anxiety and felt helpless in not being able to reassure him. Tim’s parents knew that he blushed a lot at school whereas at home he was much more relaxed. The parents were discussing repetition of the fourth grade with the CC because of the little progress that Tim made during the school year. They thought that their son was “a sweet, open and bright boy”, but that his fears interfered with his ability to learn. They thought that Tim not only had low test scores, but also had actually learned less than he would have done when he had not been anxious. The symptoms seemed to have developed over a period of one year. The onset of test anxiety at this age falls within the normal range.

Tim completed two self-confidence subscales of the School Attitudes Questionnaire (SAQ; 21): expressive skills and self-confidence in examinations. The SAQ is a psychometrically sound and well-accepted diagnostic tool in the Dutch educational system. Each of the SAQ items consisted of a proposition, and the participant is asked to judge if the proposition is applicable to himself or herself on a short Likert-type response scale that has three options: that is the case , I don’t know , and that is not the case . Construct validity and reliability of these scales are good 21 . In comparison to the norm scores, Tim showed confidence well below the average (stanine 3) on the self-confidence in examinations scale (an example of an item is: During a school test I am usually calm and able to work with concentration ) and extremely low (stanine 1) on the expression scale (an example of an item is: I get shy when everyone in the classroom suddenly looks at me ).

Treatment Plan

In this study, a Dutch program was used entitled “Je kunt meer dan je denkt” (literally translated to “You can do more than you think”, a Dutch expression meaning that you shouldn’t underestimate your abilities). It is a program for small groups of children aged 6-12. It consists of eight sessions and one booster session. The sessions took place in the two months prior to summer vacation and the booster session was given in the second week of the new school year. The intervention was given on Mondays directly after school, in the remedial teaching classroom of the school. Besides Tim, five other children participated: four girls (one of which was from the same classroom) and one boy, which was Tim’s nephew, who was in the third grade.

The core components of CBT are: teaching children to identify and label irrational thoughts and to replace them with positive self-statements or modify them by challenging their veracity (cognitive component); exposure and relaxation training (behavioral components) 22 . These components were integrated in each session, that consisted of: a summary of the last session, discussion of the homework, introduction of a new topic, relaxation exercises, exposure, a game, complimenting oneself (the children wrote down something that they were proud of), and reviewing the session. The exposure consisted of the children taking turns to stand in a puppet theater and talk about a predefined topic. The children were allowed to choose for how long they would talk and could choose to hide in the puppet theater. The games intended to allow children practice group presentations in a fun way. After each session, the children received a letter with a summery and a homework assignment.

Course of Treatment

In the first session, the psychologist introduced herself with a collage, then talked with the children about why they were in the intervention group and what they would like to learn. Tim said that he would like to become less anxious and that he wanted to ‘stop blushing so frequently’. He said: “I hate it when it happens. I feel it and I just know that my face is all red”. A story was told about a child with test anxiety and afterwards the children discussed what they recognized. Tim recognized the emotional, cognitive and physical symptoms that were included in the story. The rules were made together with the children. They were formulated positively (e.g., we are quiet when another person is talking, we are kind to each other). The children then did a game pretending animals in duo’s and the others had to guess. Tim complimented himself on making a rule. In reviewing the session, it was clear that Tim had experienced some nervousness, but nevertheless also felt sufficiently safe. While talking, Tim blushed several times.

The children had to introduce themselves with a collage that they had made as a homework assignment. Tim was clearly nervous when doing so, but the positive responses of the other children seemed to reassure him. The breathing exercise went really well. The exposure exercise was more difficult. Tim choose to present himself, and used two sentences. He was blushing. Afterwards a game with different types of moving (e.g., running, jumping) was played. Tim anxiously observed the behavior of the others, but during the game did become a bit more brave in his behavioral expression. He complimented himself on doing all the exercises.

Tim had successfully worked with the homework assignment (repeating the relaxation exercised). The topic explained and discussed was emotions. The children then played a game pretending they entered a bus, and each time all the passengers would show the same emotional expression as the child who entered. Tim really enjoyed the game. He asked if it could be repeated, which was done after the session was officially finished. The relaxation went well and during the exposure exercise Tim showed slightly more fun, although was still blushing. He answered a question of one of the girls. An exercise was done in which the children had to walk to the belonging emotion labels that were spread around the room while the psychologist mentioned short situations. Tim was able to explain his answers and showed emotional insight. Tim complimented himself on being kind. During the session Tim asked the other children whether he was blushing. He had to smile when one of the others told him that he did, but that it was cute.

Tim had spent a lot of work on his homework assignment collecting pictures from newspapers and magazines with emotions on them. The cognitive model of emotional response was explained and practiced using the smart board with several examples. After the relaxation and exposure exercise, the children also role-played several situations, thoughts and feelings according to the model. Tim again asked the other children whether he was blushing and opened up about his feelings of embarrassment when classmates laughed about him at moments of blushing. The more positive responses from his peers in the group seemed to help. He further was stimulated to try the relaxation techniques (which was homework again) at times when he felt he would blush. Tim complimented himself on cooperating so well.

This session, the children learned to discriminate between positive, helping thoughts and negative thoughts. Tim was quite able to make this distinction, but found it very hard to think of positive thoughts that he could use for his real-life examples. He accepted help from the other children. As a game, the children had to act crazy. Tim tried a few odd dancing steps, but mainly laughed which seemed to be his way to escape out of a situation he found uncomfortable. Nevertheless, during this session Tim did not blush. Tim complimented himself on getting hot chocolate for everyone at the start of the session.

In this session, the children further worked on replacing their negative thoughts. In the relaxation exercise, not only breathing and bodily techniques were used, but also dreaming about positive events. The game of the second session was repeated, but this time the children were asked to move in a way that corresponded with certain thoughts (e.g., I can do this!). Tim had worked on altering his thoughts and showed improvement in finding positive thoughts. Tim volunteered to be second in the exposure exercise. He complimented himself on being more present in the group. Tim had blushed only during the game.

The children learned that it is OK to make mistakes. Tim had also heard this message before by his parents and teacher and was very willing to share experiences with the other children. In the game children had to move objects in a circle without using their hands. The exposure went really well. Tim took several minutes. During the relaxation exercise, Tim was laughing with one of the girls. Tim had not blushed during this session. He complimented himself for helping others.

The topic was finding solutions for problems. Tim participated well. In the game the children worked together in two teams getting across the room in different ways and Tim showed some initiative, that he later complimented himself on. The exposure exercise went as well as the previous session. Tim felt sorry that it was the last session. Tim had not blushed.

End of program

After the eight sessions, the parents were given information about Tim’s progress. They also received advice on how to help Tim with relaxation and changing negative thoughts into helpful thoughts. In the booster session, the children received a reminder of all the techniques that they had learned. Tim enjoyed this session and made a relaxed impression.

Observations

Observations during the sessions revealed decreases in Tim’s anxiety and blushing. The parents were interviewed after the eight sessions and they felt that there was a significant decrease in Tim’s fear of failure. They still agreed that it would be best for Tim to repeat the fourth grade and had more faith that he would make progression now.

Interview with Tim

On the booster session, Tim was interviewed during the booster session. He was happy to share some positive experiences.. He said that he felt that although it was exciting to be in a class full of new children, he felt more secure than in the past and had already made some new friends. This was an expected improvement, as in the last session, Tim had explained that even thought his confidence in expression was low, he felt that he would be able to become more experienced and he seemed highly motivated to show more social initiative. Further, Tim now thought he blushed much less frequently and he explained that: “I now also know that a lot of children do not think it is stupid when I blush”. With schoolwork he found it easier to concentrate and he thought that he would become one of the brightest students of his classroom now he felt more confident.

Questionnaire

On the SAQ, Tim had shown an increase in confidence directly after the eight sessions: his self-confidence in examinations had become average (stanine 6) and his confidence on the expression scale had grown, but was still low (stanine 2). At the second post-intervention assessment (booster session), his confidence on both scales was above average (stanine 8 and 9 respectively). For a picture of the whole group improvement, the graphs of the raw scores of all children are presented in Figure 1

As can be seen, all children showed improvement on at least one of the two scales.

The reliable change index is a statistic that we can use to work out whether a change in an individual’s score is statistically significant, based on how reliable the measure is. It is defined as the change in a client’s score divided by the standard error of the difference for the test(s) being used. If the RCI is 1.96 or greater, then the difference is statistically significant (1.96 equates to the 95% confidence interval). For the scores of Tim, the improvement in self-confidence in examinations was significant on both occasions: RCI 1 = 5.22 and RCI 2 = 7.14, when compared to the pre-intervention measurement. The improvement between the first and second post-intervention assessment was significant as well (RCI = 2.24). Similarly, for Tim’s confidence on the expression scale, although the short time improvement was clinically small (from a stanine 1 to a stanine 2), it was significant (RCI 1 = 3.08) and the improvement on the second post-intervention assessment was also significant RCI 2 = 10.77. The improvement between the first and second post-intervention assessment of expression confidence was significant as well (RCI = 7.69).

Interview with the Teacher

For the long term evaluation of Tim’s success, Tim’s sixth grade teacher was interviewed three years later. This is the last grade of primary school in the Netherlands. Tim’s teacher said that she knew Tim as a very gentle and kind boy. He did not seem anxious and there were no signs of test anxiety or social inhibition. According to the teacher: “Tim can sometimes feel a bit shy in new, social situations, but then he is able to discuss this.” The teacher did not notice any blushing in Tim anymore.

School Advice

For the final outcome, Tim’s academic success, we looked at his performance on the official national test that children take in the sixth and that is used to inform the parents and the school about the child’s appropriate high school level (in combination with the impression that the school has formed). On this test, Tim received advice to go to senior general secondary education (HAVO) , which qualifies students to enter higher professional education (HBO).

In this study, it was investigated what the effects of a small group CBT were for a case of test anxiety with extreme blushing. The current paper described the improvements of Tim during a program that was given in weekly sessions. Multiple informants and methods provided information that supported that the program was sufficient for both the anxiety as well as the blushing. The positive effect on the school achievement was also supported. The findings therefore confirmed our hypotheses.

With respect to the blushing, it was found that no adjustments to the program needed to be made. The blushing was, however, given attention to in response to initiatives of Tim to share his feelings on this topic. Within the small group CBT there it was possible for all children to share their thoughts and feelings and specific concerns. This may be a factor that is essential to meet the specific needs of all children in a group based program. For this purpose, it seems essential to create a therapeutic environment that feels safe and secure 23 . The relationship with the psychologist 24 , but also feelings of safety and friendship between the children should be fostered as these aspects are an important precondition for emotional disclosure in school-aged children 25 . Making positive rules together with the children (e.g., ‘We listen to each other’) and verbally reinforcing prosocial behavior are concrete examples of how this can be established.

The improvement in Tim’s confidence in expressing himself in the presence of others showed a ‘sleeper effect’ (i.e., a delayed effect of treatment) 26 . This effect might have occurred because Tim needed more practice and positive experiences before an increase in confidence could be achieved. During the treatment, Tim already showed great improvement in the exposure exercise, but there are many different situations in which expression oneself for an audience is needed (e.g., getting a turn in class or being invited for a social event). What is interesting is that Tim already expressed self-assurance in using the learned techniques in order to become more confident directly after the program. When the results of an intervention seem to be disappointing, it therefore might be informative to ask children about their faith in further improvement and to monitor this.

In conclusion, this case study is an illustrative example of how small group CBT can be applied in the school setting. The gap between research and practice needs to be narrowed because the school setting can have a great impact on a child and is also an important setting where children present mental health problems. The current problem of test anxiety is a clear example of this. The success of the intervention supports the possibilities of schools in fostering a healthy socio-emotional development in children.

Acknowledgements

With thanks to the child, parents and school to give their permissions. There were no conflicts of interest for the author of this paper. She was working on a voluntary basis.

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• Case study: How CBT can be applied in the treatment of depression

The aim of this case study is to show through the use of a client study, how cognitive behavioural therapy ( CBT ) can be applied in the treatment of depression . The patient is a woman with a 2-year history of depression connected with low self-esteem , guilt and shame. An account of the CBT treatment carried out over 12 sessions is given. Noticeable improvements on measurements of mood and hopelessness, with an improvement in social and occupational functioning were achieved.

Mary is a 26-year-old nurse, who was referred for treatment for the management of depression. She presented with a 3-year history of depression along with issues related to low self-esteem and relationship problems, she was referred by her GP after being prescribed various forms of antidepressant medication over a 2-year period, this medication did not seem to be effective.

Presenting problems

Mary’s depressive symptoms lead to her social and occupational functioning being impaired. She found it difficult to complete tasks related to her job, and had been disciplined at work even though she had previously excelled in her role. She explained that she felt somewhat uncomfortable at work and found making conversation with colleagues quite challenging. She considered herself to be ‘dull’, ‘boring’ and ‘unlikeable’, which as a result lead to her isolating herself socially. Over the course of her depression she decreased her pastimes and social activities, and started to use all her free time on her own, in bed or “attempting to catch up on tasks related to her job.”

Mary was in a relationship with Angela, who lived in Scotland with her two year old son. Angela was still married to her husband when they first met and Mary felt guilty for “ruining a marriage,” and “being involved in a same-sex relationship”, therefore, this was a part of her life that she didn’t tell people about. She explained her reason for keeping this to herself was due to a fear of people judging and rejecting her over it. She also did not feel secure in the relationship and had fears about Angela’s commitment to her although she did not want to end the relationship.

Mary has a sister who is two years older than her who also has a history of depression, she sees this sister as being a good form of support. She states that she also has a good relationship with her father although “he is not in touch with my generation” and therefore “he’s not really able to understand me”.

Mary’s mother died in a car crash when she was 10 years old. She described them as having a close relationship and found the first year after her mother’s death a particularly difficult time. Mary remembers her childhood as being a happy one where she spent lots of time with her parents, who had a good relationship with one another.

Mary has no previous history of therapy but had a good awareness of her difficulties and was willing to engage in a time-limited treatment of CBT as well as continuing to take the antidepressants which her GP prescribed.

Treatment outcome measures

Variations in levels of depression and anxiety were assessed using the Beck Depression Inventory (BDI) (Beck & Steer, 1993a), and Beck Hopelessness Inventory (BHI), (Beck & Steer, 1993b). Both the BDI and the BDI have been extensively tested for reliability and validity (Conoley, 1987; Dowd, 1992; Owen, 1992). These Measures were administered pre-therapy, mid-therapy, and post-therapy. The Improving access to Psychological Therapy service (IAPT) also recommends routine use of a combination of questionnaires, the PHQ-9 for depression, GAD-7 for anxiety, and three IAPT phobia scales (social, agoraphobia, and specific phobia) as well as the Work & social adjustment scale which assesses problems in functioning with work, home management, social leisure activities, private leisure activities, and family & relationships and therefore these measure were administered at the start of each session. Mary’s score on both phq-9 (16) and the BDI (32) indicate moderately severe depression, her GAD-7 score was 9 which translates as mild anxiety, WSAS scores for Mary were 18 which is associated with significant functional impairment. The IAPT phobia measures indicated that she would markedly avoid social situations and she would definitely avoid certain situations for fear of having a panic attack. Becks Hopelessness scale which was administered in order to help assess where she was at risk of suicide, Mary scored 17 on this scale which identifies severe hopelessness, Mary confirmed occasional thoughts of a suicidal nature however she denied any intent to act on these thoughts as she felt she would be letting everyone down.

FORMULATION

Case Conceptualisation

A cognitive case conceptualisation is a method of considering a client’s problems and issues using the cognitive model of emotional disorders (Beck, 1987). It includes beliefs (automatic thoughts, underlying assumptions, and schemas), emotional reactions, behavioural strengths and deficits, social factors that influence problems, and consideration of biological factors and maintaining cycles of the client’s difficulties. The conceptualisation, constructed with the client, can be amendment through the course of treatment and can used as a directive for any problems that arises for the client both outside of therapy and in the therapeutic relationship, it can also can act as a   “map” for the therapist (Persons, 1989).

Figure 2. The cognitive model as applied to depression (Persons, 1989).

After Mary’s initial assessment the therapist drew up a longitudinal formulation to help her consider Mary’s difficulties and plan treatment. This longitudinal formulation included the following.

Early experiences: Need to please mother, parents not socializing outside family home, loss of mother.

Core beliefs :

I am not likeable (As I’ve never had a lot of friends at any time in my life), I am not good enough and can never achieve enough (My sister and classmates were always better than me), I am a bad person (As I started a relationship with person of the same sex).

Irrational Rules/Assumptions :

‘If I date someone of the same sex, I am a bad person’, ‘If I tell my friends about my same sex relationship, they will disapprove and reject me’, ‘If I take on all the duties assigned to me at work’ (regardless of my large workload), ‘my workmates will like me, If I tell anyone that I suffer from depression, they will think that I am crazy’.

Precipitating factors :

A precipitating factor for Mary’s in her life was the start of a same sex relationship. Mary feels that people would not accept her because of this. As a result she prevented others from becoming to close to her to avoid having to reveal her secret.   This avoidance of social activity resulted in her spending more time at home by herself which precipitating her depression.

Figure 3. Formulation drawn up collaboratively with Mary based on Mooey’s (2010) depression model.

Perpetuating factors

The therapist used Mooray’s (2010), “The Six Cycles Maintenance Model” model to investigated Mary’s thoughts, feelings, behaviour and physical response (Figure 3) and collaboratively conceptualize Mary’s presenting difficulties while socializing Mary to the cognitive model by showing links between thoughts, feelings, behaviours and physical sensations. This diagram was used as a “road map” to help the therapist identify and focus on factors that are likely to be important in Mary’s depression and a rationale for the therapy interventions that the therapist would include in treatment (see figure 3).

The therapist helped Mary looked at a number of maintenance cycles which were feeding back into Mary’s difficulties, for instance when Mary is around her workmates she often has the automatic thought “Nobody likes me, I will never be able to form friendships”, as a result she becomes upset and feels rejected and goes on to isolate herself from workmates by avoiding them and having lunch on her own and therefore does not break the pattern of feeling uncomfortable around her workmates and rejected by them.

1. Negative Automatic Thoughts

As a consequence of feeling low Mary’s was having more negative automatic thoughts (NAT’S) about particular situations. These NAT’S seemed highly credible to her and came up regularly without much of her awareness. These NAT’s may have kept Mary’s negative core experiences going.

2. Ruminations and self-attacking

Mary sometimes found herself getting locked in ruminative, self-attacking thinking cycles of how she made so many mistakes and should have done things differently along with other self-attacking thoughts related to being weak and not good enough as a person.

3. Mood/Emotion

Mary identified various emotions connected to her depression which she frequently experienced such as stress, depression, unhappiness, dejection, guilt, shame and feeling sad about feeling sad all of which feed back into the her difficulties.

4. Withdrawal and avoidance

Throughout Mary’s depression she had isolated herself from others and avoided socializing and did not allow others to become close to her. She believed that she would not enjoy activities or be able to accomplish the things she wanted to. As a result of this avoidance she was not allowing herself the opportunity to test the truth behind her negative beliefs and limited her opportunity to find enjoyment or a sense of achievement from activities.

5. Unhelpful behaviours

Mary’s attempts to improve her emotions or balance her negative beliefs included taking on excessive work loads and seeking approval from others. These behaviours made her feel better in the short term but were part of what maintained her difficulties in the long term.

6. Motivation and Physical Symptoms

Mary’s physical symptoms of depression included feeling tired, tearful, on edge and having sleeping difficulties. These physical symptoms feed back into Mary’s depression leading to even less activity and contributing to a downward spiral

Therapeutic goals

Mary stated that through therapy she would like to focus on achieving the following:

• To disclose to her sister and friends about her relationship with Angela;
• To feel more secure with Angela, to discuss their relationship and plans for the future;
• To achieve better ways of managing her time, and allocate more time for leisure activities;
• To become better at communicating with people at work and no longer take on an excessive workload; and
• To feel more at ease in social situations particularly at work.

Treatment contract

Guidelines on the duration of treatment length suggest that most of the progress made in CBT treatment is thought to take place in the first twelve treatment sessions, and additional improvements are moderately low when treatment carries on for further sessions (Barkham & Hardy 2001). If this is the case, the duration of the CBT treatment offered should be kept within this time frame. With this in mind an initial contract of 6 sessions was agreed on which was extended for a further 6 treatment sessions.

Assessment sessions 1-3

The early sessions were spent collecting client information, building therapeutic rapport, discussing issues around confidentiality and taking baseline treatment measures (see table 3). The therapist and Mary also looked at the foundations of the CBT approach and how it might be useful, the idea of working together using a structured, and focused method, with the requirement of weekly out-of-session assignments, and the opportunity to regularly review the treatment. The meaning of core beliefs, assumptions, and NAT’s were looked at and Mary started to recognize and document a number of these, many of which the therapist and Mary planned on returning to later when completing thought Records and developing Behavioural Experiments in sessions. The therapist and Mary also constructed the cognitive case conceptualisation (Figure 2.) over the three assessment sessions drawing up maintenance cycles and getting Mary to consider what could be done to try and break out of these patterns.

Sessions 4-8

As part of her out-of-session assignments Mary completed Weekly Activity Schedules (WAS) in order to monitor the activities she was involved in for each hour of each day, and to note the amounts of pleasure and mastery (feelings of accomplishment and effectiveness) actually experienced during each activity. She assigned a percentage rating to her mood for each activity she participated in and we made the connection between her mood and the activity. It discovered that Mary’s mood was worst when she was least active. After making this discovery the therapist worked with Mary to help her come up with a list of activities that she currently enjoys or used to enjoy as well as activities that gave her a sense of achievement. The therapist used Beck’s (1987) evolutionary model of depression to explain to Mary that when people have depression these activities might not be easy to do but if there is no investment there is no return. Therefore it can be useful to plan these activities in an attempt to strike a balance between pleasure and achievement. The therapist encouraged Mary to make time for these activities several times a week and explain how scheduling something makes people more likely to commit to it and that she should try to do the activities she has planned regardless of her mood. Mary monitored the outcome of this activity scheduling by taking regular mood ratings and noticed her mood ratings improved on the days she engaged in the pleasurable activities she had planned.

Mary completed a Daily Thoughts Record (DTR), which we used to investigate her thinking patterns. At first she found it hard to recognize her “hot thoughts” (automatic thoughts that carry the strongest emotional charge) and “alternative balanced thoughts.” To overcome this difficulty the therapist suggested that Mary try to note down the thoughts and feelings that go through her mind as close to the time she is feeling the strong negative emotion as possible. Mary started to enter brief notes onto her mobile phone when she felt a strong negative emotion and would later enter the information into a thought record. The therapist helped Mary use the items she had identified on the DTR as a ‘courtroom’ to challenge her hot thoughts by looking at evidence to support the hot thought and evidence that does not support the thought and consider a more balanced alternative. One of the ‘hot thoughts’ that Mary identified was on the DTR was ‘All hell will break loose if tell anyone about my partner’. After identifying this thought the therapist helped Mary consider further what might take place if she were to disclose to her housemate Tamara about her partner Angela. The therapist asked her to think about how Tamara might respond if roles were reskilled and if Tamara was the one who disclosed the information; or how Mary would react if her friend did not choose to reveal the information to her? Mary was amazed at how her beliefs and automatic thoughts as well as the intensity of her feelings could change so much.

In session seven the therapist and Mary set up a behavioural experiment to test out what would happen if she disclosed her sexuality to her flatmate. Despite the previous work on Mary’s thoughts related to this she still believed 90% that people would reject her in some way if she disclosed her sexuality. In relation to her flatmate she believed in the worst case she would chooses to move out after the disclosure or in the best case she would start spending less time with her. An alternative belief that Mary considered was that people would be surprised at the disclosure but they would not treat her any differently which she stated she believed 10%.

Mary returned in session 8 and had revealed the truth about her relationship with Angela to her housemate who at first became angry that Mary had hid it from her. During further talks with her housemate, Mary told her about her depression, the fact that she was seeing a therapist, and her problems coping with the death of her mother. Mary was surprised by her roommate’s positive reactions and later went on to share similar information with her sister. Mary re-rated her belief that people would reject her in some way if she disclosed her sexuality as 40% and re-rated the alternative believe as 60%.

Sessions 9-12

We looked at the beliefs Mary’s held regarding how she thought others saw her. She believed that everyone she knew found her boring, and then gave an account of how someone would act if they found someone “boring.” We agreed on carrying out a behavioural experiment that could be done during her break at work. This consisted of her observing her workmates and purposely watching for any proof of them being bored by what she was saying. Before the experiment, she assigned a rating to her belief (on a scale of 0-100%). After doing the experiment, she found no definite confirmation of people being bored and she rated her belief again. The rating of her belief after the experimental belief was less (55%) than before the experiment (95%). She carried out the behavioural experiment a few times in different situations, which eventually helped her see that in fact people did not regard her as boring. As a result Mary started to engage more in conversations with her workmates and attended a social event that her colleagues invited her to outside of work.

TREATMENT OUTCOME

At the time of discharge, there were noticeable improvements in Mary’s mood, levels of hopelessness, as well as overall social and occupational functioning. Mary became able to discuss her history of depression, the relationship with her partner , and the bereavement of her mother with people in her life. She disclosed her depression to her manager, who was understanding and compassionate. He arranged to temporary decrease her workload and planned regular meetings to talk about any difficulties at work. She was able to manage her time better and included leisure activates into her week. This progress can also be seen in the scales that were administered at intake, mid-therapy and discharge (seen table 4).

Table 3. Treatment outcome measures. (Beck & Steer RA, 1993a, 1993b & 1993c; Saunders et. al, 1993), (PHQ-9, GAD-7 & WSAS; part of the IAPT Minimum data set).

The rating of depression decreased significantly over time, shifting from being in the severe depression range to being in the mild depression range (BDI: 15, PHQ-9:4). The BHI scores also improved over time, showing a decline in the intensity of hopelessness. The score on the BHI of 6 was no longer showing an indication of high psychological distress. Mary’s GAD-7 (4) and Work   and Social Adjustment Scale scores (2) also decreased to subclinical levels.

Relapse prevention

In relation to preventing set backs she has kept records of material from the therapy sessions (homework and sheets from sessions) and a relapse prevention plan and states that she looks over them at times, particularly when she is experiencing low moods or particular difficulties. This self-conducted regular review of therapy sessions may assist in increasing her chances of maintaining the improvement achieved.

The ending of therapy with Mary was carefully thought out particularly because of the losses she experienced in the past. At the start of treatment we block booked all the dates we would meet on and Mary was reminded by the therapist midway through the sessions of the date they would end therapy on, the therapist again reinstated this a number of weeks before the end. The therapist regularly checked out how Mary was feeling about ending therapy and allowed Mary the space to discuss any fears she had about ending.

This case study looked at using a cognitive behavioural approach with a client with depression. The client improved in terms of mood, hopelessness, and overall social and occupational functioning. This outcome backs up various published research findings which provide evidence for the benefit of CBT in treating depression, (Rush, Kovacs & Beck, 1981; Scott, 2001; Department of Health, 2001).

Mary stated that she views her positive outcome as being a result of a mixture of CBT and medication treatment; though, she expresses the CBT treatment as being the more beneficial. She stated that CBT had “changed her way of seeing things” and provided her with a “method or system,” allowing her to steadily sort through and resolve any difficulties she experienced. This schema modification together with the restructuring of her cognitive account of depression may reduce her risk of relapsing.

Upon receiving this referral the therapist had some initial anxiety about working with a case presenting with difficulties related to her sexuality as the therapist did not have previous experience of working with patients with this type of presentation. Another difficulty was that this was only the therapist’s second depression case she had treated and this lack of experience added further concern for the therapist initially. However the therapist found the support of supervision beneficial and quickly realised that many of the techniques she had used before could also be applied to this case.

A limitation to Mary’s treatment was that she was only offered 12 sessions of CBT due to organisational restrictions which is less than recommend dose of 16-20 weeks for moderate to severe depression, (NICE, 2007a). It may have been beneficial to offer a further four to six sessions to allow the opportunity to tackle some of Mary’s rules and assumptions and therefore reduce the risk of relapse. However evidence which is contrary to this suggests that most of the progress made in CBT treatment occurs in the first twelve sessions, and further progress is moderately low after this (Barkham & Hardy, 2001). It will have been interesting to follow-up the outcome of this case at a later date to investigate the long-term effects of the treatment.

***If you’re struggling with your mental health and think you might benefit from speaking to someone, we offer a FREE 15-MINUTE CONSULTATION with one of our specialists to help you find the best way to move forward. You can book yours  here.

About the author

Dr Becky Spelman is a leading UK Psychologist who’s had great success helping her clients manage and overcome a multitude of mental illnesses.

***If you think you might benefit from speaking to someone about the issues in this article, we offer a FREE 15-MINUTE CONSULTATION with one of our specialists to help you find the best way to move forward. You can book yours here

Barkham M, & Hardy GE. (2001). Counselling and interpersonal therapies for depression: towards securing an evidence-base. British Medical Bulletin. 57, 115-32.

Beck A.T. (1987) Cognitive models of depression, Journal of Cognitive Psychotherapy: An International Quarterly , 1, 5-37.

Beck AT, Rush AJ, Shaw BF, Emery G. (1979) Cognitive therapy of depression. New York: Guilford Press.

Beck A.T, Steer RA. (1993a) Manual for the Revised Beck Depression Inventory. San Antonio, TX: Psychological Corporation,.

Beck A.T, Steer RA. (1993b) Manual for The Beck Anxiety Inventory. San Antonio, TX: Psychological Corporation.

Beck, A. T. (1967). Depression: clinical, experimental, and theoretical aspects . New York: Hoeber Medical Division, Harper & Row.

Burns, D. D. (1999). Feeling good: The new mood therapy . New York: Avon Books.

Champion, L. A., & Power, M. J. (January 01, 1995). Social and cognitive approaches to depression: towards a new synthesis. The British Journal of Clinical Psychology / the British Psychological Society, 34, 485-503.

Colman, I., Ploubidis, G. B., Wadsworth, M. E., Jones, P. B., & Croudace, T. J. (January 01, 2007). A longitudinal typology of symptoms of depression and anxiety over the life course. Biological Psychiatry, 62, 11, 1265-71.

Conoley, C. W. (1987). Review of the Beck Depression Inventory (revised edition). In J. J. Kramer & J. C. Conoley (eds.), Mental measurements yearbook, 11th edition (pp. 78- 79). Lincoln, NE: University of Nebraska Press.

Dowd, E.T. (1992). “Review of the Beck Hopelessness Scale.” Eleventh Mental Measurement Yearbook, 81-82

Moorey, S. (January 01, 2010). The Six Cycles Maintenance Model: Growing a “Vicious Flower” for Depression. Behavioural and Cognitive Psychotherapy, 38, 2, 173-184.

National Institute for Health and Clinical Excellence (2007a). ‘Depression: management of depression in primary and secondary care’. NICE website. Available at: https://guidance.nice.org.uk /CG23/quickrefguide/pdf/English ( accessed on 15 Nov 2010).

Owen, S.V. (1992) “Review of the Beck Hopelessness Scale.” Eleventh Mental Measurement Yearbook, 82-83

Rush A, Kovacs M & Beck A. (1981), Differential effects of cognitive therapy and pharmacotherapy on depressive symptoms. Journal of Affective Disorders ; 3, 221-229.

Persons J.B. (1989) Cognitive therapy in practice: A case formulation approach. New York, Norton Press.

Scott, J. (2001). Cognitive therapy for depression. British Medical Bulletin. 57 (1), 101-113.

Categories: Cognitive Behavioural Therapy , Depression - By Dr Becky Spelman - March 1, 2024

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Clinical case study: CBT for depression in a Puerto Rican adolescent: challenges and variability in treatment response

Affiliation.

• 1 Department of Psychology, University Center for Psychological Services and Research, University of Puerto Rico, Río Piedras, San Juan, Puerto Rico. [email protected]
• PMID: 18781640
• DOI: 10.1002/da.20457

Background: There is ample evidence of the efficacy of cognitive-behavioral therapy (CBT) for depression in adolescents, including Puerto Rican adolescents. However, there is still a high percentage of adolescents who do not respond to a standard "dose" of 12 sessions of CBT. This clinical case study explores the characteristics associated with treatment response in a Puerto Rican adolescent and illustrates the challenges and variability inherent in CBT treatment for major depressive disorder (MDD) in youth.

Methods: The patient is a 15-year-old adolescent female who at pretreatment presented a diagnosis of MDD with severe depressive symptoms, high suicidal ideation, low self-concept, and highly dysfunctional attitudes. CBT treatment consisted of 12 standard individual therapy sessions plus four additional sessions, and one family intervention. A case study method was used. Both qualitative and quantitative data for the case are presented using self-report instruments, clinical case notes and recordings of therapy sessions.

Results: Some of the characteristics she presented that have been associated with partial or no response to therapy were: increased severity of depressive symptoms, a prior MDD episode, co-morbidity with other mental disorders, and significant parental conflict. At termination the patient presented decreases in depressive symptoms, dysfunctional attitudes, and suicidal ideation, as well as improvements in self-concept. These improvements were maintained up to 1 year posttreatment.

Conclusions: Cultural issues are discussed in terms of the potential for parental conflict to perpetuate the patient's depressive symptoms.

(c) 2008 Wiley-Liss, Inc.

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Case Example: Jill, a 32-year-old Afghanistan War Veteran

This case example explains how Jill's therapist used a cognitive intervention with a written worksheet as a starting point for engaging in Socratic dialogue. 

About this Example

Jill's Story

Jill, a 32-year-old Afghanistan war veteran, had been experiencing PTSD symptoms for more than five years. She consistently avoided thoughts and images related to witnessing her fellow service members being hit by an improvised explosive device (IED) while driving a combat supply truck. Over the years, Jill became increasingly depressed and began using alcohol on a daily basis to help assuage her PTSD symptoms. She had difficulties in her employment, missing many days of work, and she reported feeling disconnected and numb around her husband and children. In addition to a range of other PTSD symptoms, Jill had a recurring nightmare of the event in which she was the leader of a convoy and her lead truck broke down. She waved the second truck forward, the truck that hit the IED, while she and her fellow service members on the first truck worked feverishly to repair it. Consistent with the traumatic event, her nightmare included images of her and the service members on the first truck smiling and waving at those on the second truck, and the service members on the second truck making fun of the broken truck and their efforts to fix it — “Look at that piece of junk truck — good luck getting that clunker fixed.”

After a thorough assessment of her PTSD and comorbid symptoms, psychoeducation about PTSD symptoms, and a rationale for using trauma focused cognitive interventions, Jill received 10 sessions of cognitive therapy for PTSD. She was first assigned cognitive worksheets to begin self-monitoring events, her thoughts about these events, and consequent feelings. These worksheets were used to sensitize Jill to the types of cognitions that she was having about current day events and to appraisals that she had about the explosion. For example, one of the thoughts she recorded related to the explosion was, “I should have had them wait and not had them go on.” She recorded her related feeling to be guilt. Jill’s therapist used this worksheet as a starting point for engaging in Socratic dialogue, as shown in the following example:

Therapist: Jill, do you mind if I ask you a few questions about this thought that you noticed, “I should have had them wait and not had them go on?”

Client: Sure.

Therapist: Can you tell me what the protocol tells you to do in a situation in which a truck breaks down during a convoy?

Client: You want to get the truck repaired as soon as possible, because the point of a convoy is to keep the trucks moving so that you aren’t sitting ducks.

Therapist: The truck that broke down was the lead truck that you were on. What is the protocol in that case?

Client: The protocol says to wave the other trucks through and keep them moving so that you don’t have multiple trucks just sitting there together more vulnerable.

Therapist: Okay. That’s helpful for me to understand. In light of the protocol you just described and the reasons for it, why do you think you should have had the second truck wait and not had them go on?

Client: If I hadn’t have waved them through and told them to carry on, this wouldn’t have happened. It is my fault that they died. (Begins to cry)

Therapist: (Pause) It is certainly sad that they died. (Pause) However, I want us to think through the idea that you should have had them wait and not had them go on, and consequently that it was your fault. (Pause) If you think back about what you knew at the time — not what you know now 5 years after the outcome — did you see anything that looked like a possible explosive device when you were scanning the road as the original lead truck?

Client: No. Prior to the truck breaking down, there was nothing that we noticed. It was an area of Iraq that could be dangerous, but there hadn’t been much insurgent activity in the days and weeks prior to it happening.

Therapist: Okay. So, prior to the explosion, you hadn’t seen anything suspicious.

Client: No.

Therapist: When the second truck took over as the lead truck, what was their responsibility and what was your responsibility at that point?

Client: The next truck that Mike and my other friends were on essentially became the lead truck, and I was responsible for trying to get my truck moving again so that we weren’t in danger.

Therapist: Okay. In that scenario then, would it be Mike and the others’ jobs to be scanning the environment ahead for potential dangers?

Client: Yes, but I should have been able to see and warn them.

Therapist: Before we determine that, how far ahead of you were Mike and the others when the explosion occurred?

Client: Oh (pause), probably 200 yards?

Therapist: 200 yards—that’s two football fields’ worth of distance, right?

Client: Right.

Therapist: You’ll have to educate me. Are there explosive devices that you wouldn’t be able to detect 200 yards ahead?

Client: Absolutely.

Therapist: How about explosive devices that you might not see 10 yards ahead?

Client: Sure. If they are really good, you wouldn’t see them at all.

Therapist: So, in light of the facts that you didn’t see anything at the time when you waved them through at 200 yards behind and that they obviously didn’t see anything 10 yards ahead before they hit the explosion, and that protocol would call for you preventing another danger of being sitting ducks, help me understand why you wouldn’t have waved them through at that time? Again, based on what you knew at the time?

Client: (Quietly) I hadn’t thought about the fact that Mike and the others obviously didn’t see the device at 10 yards, as you say, or they would have probably done something else. (Pause) Also, when you say that we were trying to prevent another danger at the time of being “sitting ducks,” it makes me feel better about waving them through.

Therapist: Can you describe the type of emotion you have when you say, “It makes me feel better?”

Client: I guess I feel less guilty.

Therapist: That makes sense to me. As we go back and more accurately see the reality of what was really going on at the time of this explosion, it is important to notice that it makes you feel better emotionally. (Pause) In fact, I was wondering if you had ever considered that, in this situation, you actually did exactly what you were supposed to do and that something worse could have happened had you chosen to make them wait?

Client: No. I haven’t thought about that.

Therapist: Obviously this was an area that insurgents were active in if they were planting explosives. Is it possible that it could have gone down worse had you chosen not to follow protocol and send them through?

Client: Hmmm. I hadn’t thought about that either.

Therapist: That’s okay. Many people don’t think through what could have happened if they had chosen an alternative course of action at the time or they assume that there would have only been positive outcomes if they had done something different. I call it “happily ever after” thinking — assuming that a different action would have resulted in a positive outcome. (Pause) When you think, “I did a good job following protocol in a stressful situation that may have prevented more harm from happening,” how does that make you feel?

Client: It definitely makes me feel less guilty.

Therapist: I’m wondering if there is any pride that you might feel?

Client: Hmmm...I don’t know if I can go that far.

Therapist: What do you mean?

Client: It seems wrong to feel pride when my friends died.

Therapist: Is it possible to feel both pride and sadness in this situation? (Pause) Do you think Mike would hold it against you for feeling pride, as well as sadness for his and others’ losses?

Client: Mike wouldn’t hold it against me. In fact, he’d probably reassure me that I did a good job.

Therapist: (Pause) That seems really important for you to remember. It may be helpful to remind yourself of what you have discovered today, because you have some habits in thinking about this event in a particular way. We are also going to be doing some practice assignments that will help to walk you through your thoughts about what happened during this event, help you to remember what you knew at the time, and remind you how different thoughts can result in different feelings about what happened.

Client: I actually feel a bit better after this conversation. 

Another thought that Jill described in relation to the traumatic event was, “I should have seen the explosion was going to happen to prevent my friends from dying.” Her related feelings were guilt and self-directed anger. The therapist used this thought to introduce the cognitive intervention of "challenging thoughts" and provided a worksheet for practice. The therapist first provided education about the different types of thinking errors, including habitual thinking, all-or-none thinking, taking things out of context, overestimating probabilities, and emotional reasoning, as well as discussing other important factors, such as gathering evidence for and against the thought, evaluating the source of the information, and focusing on irrelevant factors. 

More specifically, Jill noted that she experienced 100 percent intensity of guilt and 75 percent intensity of anger at herself in relation to the thought "I should have seen the explosive device to prevent my friends from dying." She posed several challenging questions, including the notion that improvised explosive devices are meant to be concealed, that she is the source of the information (because others don't blame her), and that her feelings are not based on facts (i.e., she feels guilt and therefore must be guilty). She came up with the alternative thought, "The best explosive devices aren't seen and Mike (driver of the second truck) was a good soldier. If he saw something he would stopped or tried to evade it," which she rated as 90 percent confidence in believing. She consequently believed her original thought 10 percent, and re-rated her emotions as only 10 percent guilt and 5 percent anger at self.

Treating PTSD with cognitive-behavioral therapies: Interventions that work

This case example is reprinted with permission from: Monson, C. M. & Shnaider, P. (2014). Treating PTSD with cognitive-behavioral therapies: Interventions that work . Washington, DC: American Psychological Association. 

Other Case Examples

• Cognitive Therapy Philip, a 60-year-old who was in a traffic accident (PDF, 294KB)
• Eye Movement Desensitization and Reprocessing Mike, a 32-year-old Iraq War Veteran
• Narrative Exposure Therapy Eric, a 24-year-old Rwandan refugee living in Uganda (PDF, 28KB)
• Prolonged Exposure Terry, a 42-year-old earthquake survivor

• Open access
• Published: 10 September 2024

Interdisciplinary CBT treatment for patients with odontophobia and dental anxiety related to psychological trauma experiences: a case series

• Yngvill Ane Stokke Westad 1 ,
• Gina Løge Flemmen 1 ,
• Stian Solem 1 ,
• Trine Monsen 1 ,
• Henriette Hollingen 1 ,
• Astrid Feuerherm 3 ,
• Audun Havnen 2 , 4 &
• Kristen Hagen 5 , 6 , 7  

BMC Psychiatry volume  24 , Article number:  606 ( 2024 ) Cite this article

Metrics details

While cognitive-behavioural therapy (CBT) is a well-established treatment for odontophobia, research is sparse regarding its effect on patients with dental anxiety related to psychological trauma experiences. This study aimed to evaluate changes in symptoms and acceptability of interdisciplinary Torture, Abuse, and Dental Anxiety (TADA) team treatment for patients with odontophobia or dental anxiety. We also wanted to describe the sample’s oral health status. The TADA teams offer targeted anxiety treatment and adapted dental treatment using a CBT approach.

The study used a naturalistic, case series design and included 20 consecutively referred outpatients at a public TADA dental clinic. Pre- and post-treatment assessments included questionnaires related to the degree of dental anxiety, post-traumatic stress, generalized anxiety, and depression. Patients underwent a panoramic X-ray before treatment. Before dental restoration, patients underwent an oral health examination to determine the mucosal and plaque score (MPS) and the total number of decayed, missing, and filled teeth (DMFT). Patients were referred to dentist teams for further dental treatment and rehabilitation (phase 2) after completing CBT in the TADA team (Phase 1). Results from the dental treatment in phase 2 is not included in this study.

All patients completed the CBT treatment. There were significant improvements in symptoms of dental anxiety, post-traumatic stress, and depression and moderate changes in symptoms of generalized anxiety. Dental statuses were heterogeneous in terms of the severity and accumulated dental treatment needs. The TADA population represented the lower socioeconomic range; 15% of patients had higher education levels, and half received social security benefits. All patients were referred to and started adapted dental treatment (phase 2).

Conclusions

TADA treatment approach appears acceptable and potentially beneficial for patients with odontophobia and dental anxiety related to psychological trauma experiences. The findings suggest that further research, including larger controlled studies, is warranted to validate these preliminary outcomes.

Trial registration

The study was approved by the regional ethical committee in Norway (REK-Midt: 488462) and by the Data Protection Board at Møre and Romsdal County Authority.

Peer Review reports

Patients with mental disorders have a greater risk of oral and dental diseases than the general population. Psychiatric diagnoses are associated with poor dental status, such as carious, missing or filled teeth or surfaces [ 1 ], and patients with severe mental illness are almost three times more likely to lose all of their teeth compared to the general population [ 2 ]. This may be caused by several individual or cumulative factors, such as the inability to perform self-care, diet and lifestyle factors, difficulties in accessing health care services, poor economic status, a negative attitude towards health care providers, shame and anxiety, difficulties cooperating with treatment, and drug use and drug treatment side effects [ 1 , 3 , 4 , 5 , 6 ].

Patients referred for dental anxiety treatment have moderately high levels of comorbid psychological conditions [ 7 ], and this patient group differs with respect to the age of onset, origins, and manifestations [ 8 ]. Individuals with high dental anxiety report more mental health symptoms, poorer oral health, more avoidance behaviour, and more irregular dental visits than those with no or low anxiety [ 9 , 10 , 11 , 12 ]. Furthermore, large variations in oral health and dental treatment needs have been found in patients with dental anxiety and phobia [ 13 , 14 ].

Patients with anxiety disorders, especially post-traumatic stress disorder (PTSD), could be especially prone to developing fears of dental treatment [ 15 ]. The study found that 42.0% of patients with PTSD reported high dental anxiety, compared to 17.6–31.3% in other psychiatric groups, and 4.2% in healthy controls [ 15 ]. Approximately 20% of female patients seeking dental care may have encountered childhood sexual abuse [ 16 ]. Patients who have experienced traumatic events may exhibit distinct psychological and emotional responses that can complicate the treatment process [ 16 , 17 , 18 ]. Furthermore, elements of abuse can resemble the dental treatment environment and make it difficult to tolerate dental treatment [ 17 , 19 , 20 ]. This suggests that it is important for treatment and professionals to be considerate of the patient’s trauma history [ 21 , 22 ].

In 2010, the Norwegian Department of Health concluded that patients who were exposed to torture, sexual abuse, and/or violence in close relationships and/or had odontophobia had inadequate treatment options in the Norwegian public oral health care service [ 23 ]. Based on an overriding goal of ensuring equal access to oral health services regardless of ethnic background, sex, personal finances, and life situations, it was decided to establish interdisciplinary “Torture, Abuse and Dental Anxiety (TADA) teams” nationally. These teams consist of both clinical psychologists and oral health professionals. TADA teams offer anxiety treatment and/or adapted dental treatment based on cognitive-behavioural therapy (CBT) principles.

Previous studies have showed promising results regarding the effectiveness of CBT for odontophobia [ 24 , 25 , 26 ]. However, there is a lack of studies specifically evaluating CBT for patients with odontophobia and dental anxiety who have been exposed to sexual abuse, violence in close relationships, or torture. To our knowledge, there is not any published studies on the effect of dental anxiety treatment in patients with post-traumatic stress symptoms related to abuse or torture in their literature review. However, we found one study that reported an effect of CBT treatment on dental anxiety in patients with post-traumatic stress symptoms triggered by previous dental treatment [ 27 ]. It is uncertain whether findings from that study could be generalized to patients with more extensive and severe trauma experiences originating from torture, abuse, or violence in close relationships.

The aim of this study was therefore to evaluate the change in symptoms from pre-treatment to post-treatment after integrated psychological and dental treatment for a vulnerable patient group who have been exposed to torture, sexual abuse, and/or violence in close relationships and/or who have odontophobia, in a naturalistic case series design, This is important given that the implementation of TADA teams is unique, and the service has not been evaluated [ 28 ].

Participants and procedure

A naturalistic case series design was used. The inclusion criteria for the TADA treatment were: (a) confirming a history of being subjected to torture, abuse, and/or violence in close relationships and/or confirming clinical symptoms of odontophobia (including blood/injection/injury- phobias), (b) being aged 21 years or more at the point of orientation, (c) being willing and having the ability to commit to a treatment plan prepared in collaboration with an interdisciplinary treatment team, and (d) understanding the rationale and treatment principles for the relevant course of treatment. The exclusion criteria were patients who: (a) had an organic disorder such as dementia, delirium, or severe memory problems, or suffered from a severe depressive disorder, mania, or ongoing psychosis at the time of evaluation, and (b) had known cognitive/language delays corresponding to an intellectual disability and were not considered to be able to benefit from the treatment approach because of this.

Patients were invited to the TADA clinic for an orientation with a clinical psychologist (1–2 appointments) after referral. During the orientation, the motivation to commit to therapy was addressed (e.g., willingness to meet at regular intervals for CBT treatment appointments and to gradually expose themselves to feared events). At the time of orientation, patients who confirmed having dental treatment difficulties (e.g., did not seek dental treatment, failed to carry out dental treatment, and/or endured dental treatment with great difficulty), and/or being exposed to sexual abuse/violence/torture, and were willing to commit to CBT treatment, underwent a diagnostic evaluation and were accepted into the TADA treatment program.

After interdisciplinary CBT treatment (phase 1), patients were referred by the first TADA team to the second TADA team (phase 2). Patients referred to the second TADA team were required to attend their first appointment unaccompanied. The first meeting involved reviewing discharge summaries from the first TADA team and developing a treatment plan for dental restoration. The second TADA dentist team (Phase 2) did not function as CBT therapists in this study. If patients did not need full-scale interdisciplinary CBT treatment at the point of orientation, they were referred directly to a TADA dentist team for adapted dental treatment. If needed, the TADA team referred patients to emergency dental treatment before or after the CBT intervention. Both interdisciplinary CBT treatment and dental treatment were delivered free of charge. The TADA dentist and dental nurse involved in phase 1 have their CBT training from continuous guidance and working in collaboration with the CBT trained psychologist. The TADA team involved in phase 2 consist of another dentist and dental nurse with basic training in CBT provided by the TADA psychologist. Both TADA teams participate in annual courses to maintain basic skills in CBT.

Prior to treatment initiation, dental anxiety was assessed with the specific phobia disorder module of the Mini International Neuropsychiatric Interview (MINI) version 7.0.2. [ 29 ] and dental fear and anxiety symptom questionnaires. Patients exposed to torture, sexual abuse, or violence in close relationships were included in the study regardless of whether the diagnostic criteria for odontophobia were met. These patients were further assessed with questionnaires assessing exposure to potentially stressful life events [ 30 ] and related posttraumatic stress symptom severity [ 31 ]. The patients answered their highest level of education completed (primary school, upper secondary school, college/university up to 5 years, or college/university over 5 years). Patients with college/university experience were defined as “higher education”. Furthermore, patients answered their current marital status (single, cohabiting/married, or in a relationship, but not cohabiting). The degree to which personal economy status had affected dental treatment execution was answered as either “not at all”, “to some extent” or “to a large extent”.

The Modified Dental Anxiety Scale (MDAS) [ 32 ] is a brief, self-administered questionnaire consisting of five questions regarding different dentist treatment situations. Each item is scored on a Likert scale ranging from “1” (not anxious) to “5” (extremely anxious). The item scores are summed to produce a total score ranging from 5 to 25. A cut-off score of 19 indicates high dental anxiety [ 33 , 34 ].

The Dental Fear Survey (DFS) [ 35 , 36 ] is a brief measure of dental anxiety and fear that consists of 20 items. Each item is scored on a Likert scale from “1” (never or not at all) to “5” (always or very much). Total DFS scores range from 20 to 100, with increasing scores indicating higher levels of fear. A total score of 20 indicates “no fear,” a score of 21–40 indicates low fear, a score of 41–79 indicates moderate fear, and a score of 80–100 indicates high fear [ 35 , 36 ].

The Stressful Life Events Screening Questionnaire (SLESQ) [ 30 , 37 ] is a 13-item questionnaire assessing lifetime exposure to various traumatic experiences. Each item represents different traumatic experiences and is scored as either “yes” or “no” depending on whether the individual has been exposed to the incident. This questionnaire was used exclusively at pretreatment to screen for exposure to potential traumatic experiences.

The PTSD Checklist for the DSM-5 (PCL-5) [ 31 ] is a 20-item questionnaire assessing 20 PTSD criteria outlined in the Diagnostic and Statistical Manual of Mental Disorders-Fifth Edition (DSM-5). Each item is scored on a Likert scale ranging from “0” (not at all) to “4” (extremely) based on the occurrence of symptoms during the last month. A total cut-off score of 33 has been found to efficiently detect PTSD [ 38 ]. Only patients who were confirmed to have been exposed to potentially traumatic life events completed the PCL-5.

The Patient Health Questionnaire-9 (PHQ-9) [ 39 ] consists of nine items measuring depressive symptoms. Each of the nine DSM-IV criteria is scored on a Likert scale ranging from “0” (not at all) to “3” (nearly every day) with total scores ranging from 0 to 27, with higher scores reflecting greater depression severity. PHQ-9 scores of 5, 10, 15, and 20 represent mild, moderate, moderately severe, and severe depression, respectively.

The Generalized Anxiety Disorder-7 (GAD-7) [ 40 ] is a brief measure for assessing symptoms of generalized anxiety disorder. The measure consists of seven items measuring worry and anxiety symptoms. Each item is scored on a Likert scale, ranging from “0” (not at all) to “3” (nearly every day). A total score above 10 is considered to be within the clinical range. The GAD-7 is also a measure of anxiety symptoms in general [ 41 ].

The mucosal plaque score (MPS) [ 42 ] is designed to evaluate oral health and oral hygiene. The index consists of two measures: a four-point mucosal score (MS) and a four-point plaque score (PS). The scores are combined, and the total score ranges from 2 to 8, with higher scores indicating poorer oral health and oral hygiene.

The decayed, missing, and filled teeth index (DMFT) quantifies a person’s total number of untreated decayed, missing, and filled teeth and is commonly used in oral epidemiology to quantify the extent of caries [ 43 ]. “Decayed” corresponds to primary or secondary caries in dentin, while “Missing” and “Filled” correspond to missing teeth due to caries, root residues/carious teeth beyond repair and filled/restored teeth with no sign of caries in dentin, respectively. 3rd molars were excluded from the DMFT evaluation, except in situations where these functioned as second molars. The index is frequently used to evaluate and monitor oral health and in oral health interventions [ 44 , 45 ].

Oral health and dental status examinations

Before interdisciplinary CBT treatment, the TADA patients underwent a panoramic X-ray (orthopantomography; OPG). OPG provides a panoramic single radiograph image of the teeth, maxilla, mandible, and adjacent tissue. OPG is a frequently employed radiological examination [ 46 ]. The TADA dentist conducted a dental status evaluation when the patients could tolerate the procedure. To evaluate a patient’s oral health status and dental treatment needs, the dentist determined their mucosal and plaque score (MPS) and the total number of decayed, missing, and filled teeth (DMFT).

CBT intervention (phase 1)

The TADA treatment consisted of two phases. In the first phase, patients were offered interdisciplinary CBT treatment before being referred to an other TADA dentist team for further dental treatment and rehabilitation (second phase).

The interdisciplinary CBT treatment team consisted of a dentist, a dental nurse, and a clinical psychologist delivering CBT together. During orientation to TADA treatment, a psychologist prepared the patient for CBT treatment by providing psychoeducation and rationale for exposure therapy, mapped catastrophic thoughts and safety and avoidance behaviours, examined the patient’s motivation for treatment, and clarified the treatment framework (e.g., treatment duration and structure, dental treatment clarification). The CBT treatment team then offered cognitive-behavioural treatment to challenge patients’ catastrophic thoughts and beliefs about dental treatment and find ways to adapt dental treatment to make it feasible. Patients with odontophobia or dental anxiety related to exposure to torture, sexual abuse, or violence in close relationships also received trauma-relevant psychoeducation and were taught skills on how to cope with trauma symptoms to facilitate new remedial learning experiences. The CBT intervention did not include trauma therapy directly focusing on the primary traumatic event. In addition to cognitive restructuring, in-vivo exposure therapies were conducted, tailored to maximize the disconfirmation of each patient’s unique catastrophic beliefs. While these exposure therapies varied somewhat among patients, the majority of CBT sessions included exposure to activities such as using dental mirrors, probes, polishing, administering anaesthesia, tartar cleaning, drilling, filling procedures, and, when necessary, the process of obtaining impressions and extracting root residues or teeth. Throughout the CBT phase, both dental healthcare professionals and a psychologist were typically present.

Anxiolytic drugs were not offered as part of the treatment intervention. The standard CBT treatment consisted of weekly therapy sessions (1–1.5 h) for up to 12 sessions. All exposure sessions were carried out in vivo in the dental office. The extent of the psychologist’s involvement during exposure sessions was evaluated on an individual basis. Additional sessions could be granted if the TADA team expected the patient to benefit from further follow-up.

Dental treatment intervention (phase 2)

Only limited dental treatment was carried out in the interdisciplinary CBT phase of the TADA treatment. In this phase, dental treatment was carried out only for the purpose of exposure and for facilitating new learning experiences. In case of acute infections and an immediate need for dental treatment before or during CBT treatment, patients were referred for dental treatment under general anaesthesia before further CBT treatment was provided. Two patients (10%) in this sample underwent dental treatment under general anaesthesia during the CBT intervention phase.

After interdisciplinary CBT treatment, patients were referred to a different TADA dentist team consisting of a dentist and a dental nurse for dental treatment and rehabilitation. This second phase of the treatment was not time limited. These TADA dentist teams were trained in CBT interventions but did not work collaboratively with a psychologist.

Statistical analyses

A repeated-measures ANOVA was conducted to examine changes in symptoms from pre- to posttreatment. The proportion of missing data was 10.5%. To address missing data, the expectation maximization (EM) method in SPSS, version 29, was utilized to replace missing values. The use of the EM algorithm is appropriate when less than 25% of data are missing and the missing data are deemed to be missing at random, which was confirmed to be the case for the present dataset (Little`s MCAR test X² (18.798), df  = 17, p  = .340).

Demographic and clinical characteristics

Twenty-seven patients were referred for TADA treatment during the designated trial period. Of these patients, we were unable to reach four patients on the waiting list to offer them an initial appointment. Furthermore, two patients declined treatment. Of these two patients, one had already managed dental treatment at the time of orientation, and the other did not want TADA treatment. One patient did not meet the inclusion criteria after treatment orientation and evaluation. Consequently, 20 consecutive patients referred to the regional TADA outpatient clinic for adults in the county of Møre and Romsdal, Norway, were included (please see Fig.  1 for the flow chart). Of these 20 patients, 12 were referred by oral health personnel (dentists, dental hygienists, oral surgeons), four were referred by general practitioners, two were referred by psychiatric services, and two referred themselves.

The flow of TADA treatment after referral

The mean time since the last dental treatment was 10.7 years (range = 0–30 years). The study participants had an average age of 41.8 years (range = 21–64 years), 75% were female, and 65% were married or cohabiting. A minority of patients had completed higher education, and half received social security benefits. A significant proportion of individuals (70%) stated that their personal finances, in part or significantly, had affected their ability to pursue dental treatment. Furthermore, the patients had been on a waiting list for a duration of 42 months prior to the start of phase 1 of the TADA treatment.

All patients in this sample met the diagnostic criteria for odontophobia, and all underwent interdisciplinary CBT treatment. No patients were referred directly to the TADA dentist team after treatment orientation. Furthermore, no patients were referred for trauma therapy before or during CBT treatment by the TADA teams. Two patients were granted additional exposure sessions (one and seven sessions).

Ten patients reported that domestic violence and/or abuse experiences were the cause of their dental anxiety. Of the other ten patients, three patients did not report traumatic incidents, while seven did not relate their abuse/violence experiences as the cause, or sustaining cause, of their odontophobia. None of the patients stated that they were survivors of torture experiences. 70% reported a history of sexual abuse, as measured by the stressful life event questionnaire. Furthermore, 65% reported exposure to violence in close relationships. 55% reported being survivors of both sexual abuse and violence in close relationships. Patients exposed to potential stressful life events reported a mean of 6.3 (range = 3–11) potential traumatic experiences.

70% of patients reported having comorbid psychiatric disorders, and six (30%) patients simultaneously received general mental health treatment. Patients did not have to end their ongoing treatments to be included in the study. The most prevalent comorbid diagnoses were mood disorders (35%), attention-deficit/hyperactive disorder (30%), and posttraumatic stress disorder (30%). Table  1 summarizes the sample’s characteristics.

There were no dropouts during the interdisciplinary CBT phase of the TADA treatment program. On average, patients received 10.8 interdisciplinary CBT sessions (SD = 2.6, range = 6–19 sessions). All patients were referred to the TADA dentist team following the completion of the CBT intervention. Additionally, all patients attended further dental appointments and initiated dental treatment and rehabilitation.

Changes in symptoms

There was a significant reduction in the symptoms of dental anxiety from pre- to post-treatment as measured with the MDAS (λ = 0.07, F (1,19) = 262.10, p  < .001, d  = 3.07). There was also a significant reduction in symptoms of dental fear as measured with the DFS (λ = 0.25, F (1,19) = 57.36, p  < .001, d =  2.18).

For the 17 patients who reported having traumatic experiences, there were large reductions in symptoms of post-traumatic stress as measured with the PCL-5 (λ = 0.56, F (1,16) = 12.43, p  = .003, d  = 3.04). For the whole sample, there was an improvement in symptoms of depression as measured with the PHQ-9 (λ = 0.50, F (1,19) = 19.36, p  < .001, d  = 1.00), and there were moderate improvements in symptoms of generalized anxiety as measured with the GAD-7 (λ = 0.74, F (1,19) = 6.60, p  < .001, d  = 0.57). A summary of the analyses is displayed in Table  2 .

Subgroup analyses were conducted to inspect possible effects of ongoing psychological treatment, and to compare possible differences between patients with and without a history of abuse. The results are summarized in supplemental Table S1 . There were no associations between ongoing psychological treatment and changes in MDAS and DFS. However, patients with ongoing psychological treatment showed less improvement in symptoms of depression and anxiety. Patients with a history of abuse reported similar changes in symptoms as patients without such history.

Oral health and dental treatment needs

The average DMFT score for the total sample was 18.8 (range 10–36). The patients in the sample had on average 6.6 decayed teeth, 5.6 missing teeth and 6.7 filled teeth. See Table  3 for the total average DMFT score and MPS. On average, patients had an MPS of 2.8 (range 2–6).

The present study aimed to evaluate the implementation of integrated psychological and dental treatment within the TADA team for a sample of patients exposed to traumatic events and/or diagnosed with odontophobia. Overall, the sample reported positive treatment outcomes. Notably, no patients declined further dental treatment after the CBT intervention, indicating that the treatment was both accepted and tolerated by the participants.It is promising that all patients in this sample completed the interdisciplinary CBT treatment intervention despite their previous psychological trauma experiences, high degree of psychiatric comorbidities, prolonged dental avoidance behaviour, and the absence of anxiolytic drug administration. Additionally, all patients were referred to and started dental treatment and rehabilitation. These results suggest that the treatment approach was acceptable for vulnerable patients with a history of traumatic experiences and patients with odontophobia. This finding is significant given that the implementation of TADA teams is unique, the service has not been evaluated, and characteristics of the specific patient group have not been described in detail [ 28 ].

There were large and significant improvements in all measures of dental fear and phobia after CBT treatment. However, some studies indicated that a relatively large proportion of patients do not show improved dental attendance despite reporting reductions in their dental anxiety level following different treatments [ 47 ]. Our findings are align more closely with a previous meta-analysis on behavioural interventions for dental fear in adults, showing medium to large effect sizes for self-reported dental anxiety after behavioural interventions and post-treatment attendance at dental visits with rates between 33% and 100% within 6 months after treatment [ 25 ]. All patients initiated dental treatment, but the study lacks information concerning long-term dental care attendance. Additionally, consistent with other research indicating wider positive life changes after CBT for dental anxiety treatment, our study found decreased symptoms of depression and generalized anxiety following treatment [ 48 , 49 ].

Most patients in our sample had a history of being exposed to potentially traumatic life experiences and had a high prevalence of comorbid psychiatric diagnoses. The significant reduction in posttraumatic stress symptoms suggest that the treatment was well tolerated and could alleviate PTSD symptoms. Although the treatment did not have a direct focus on altering the primary traumatic experience and related psychopathology, the treatment intervention did focus on managing trauma symptoms as presented in the dental care setting. The purpose of this was to make it possible for the patients to have new and corrective learning experiences with dental treatment and to alter dental-related catastrophic thoughts and behaviours. These results are thus in line with research that indicates that the exposure of patients to corrective information that violates their expectations is central to fear reduction in psychological therapy [ 50 ]. Furthermore, these results support previous findings from qualitative studies of trauma-informed treatment interventions and indicate that interdisciplinary CBT could be potentially beneficial and feasible for patients exposed to psychological trauma caused and/or maintained by reasons other than previous dental treatment experiences [ 20 , 21 , 51 ].

The patients included in this study had a formal diagnosis of dental phobia at treatment entry and had avoided dental treatment for over a decade. The longevity of dental avoidance in our sample was concordant with other findings [ 25 , 52 ]. In summary, we found significant variations in oral health and dental treatment needs as measured by the total MPS and DMFT score. Dental treatment needs were heterogeneous, varying between no/little to many dental treatment needs. We found that the dental status of the sample was in line with a previous study on treatment-seeking patients with odontophobia in Norway [ 13 ] and Sweden [ 14 ]. The Norwegian study found a DMFT mean score of 16.4 in their sample while the Swedish study found an average DMFT score of 18.6, compared to 18.8 in the current study. We also found significant variations in oral health as measured by the total MPS. This is also in line with the previous studies on dental status in treatment-seeking odontophobia patients in Norway [ 13 ] and Sweden [ 14 ]. The variations in the MPS reflect that some patients had a reduced ability for dental-related self-care behaviour, while others had an intact ability to take care of their own oral health despite severe dental anxiety.

Most patients reported having a low socioeconomic background, which could be associated with a heightened risk of dental fear [ 53 ]. Many patients in the sample (70%) stated that their personal economic status, in part or significantly, had affected their ability to receive dental treatment. These findings suggest that a considerable number of patients in the TADA intervention would have faced financial constraints, making it unlikely for them to independently pursue dental treatment due to limited financial resources. The fact that the TADA treatment (both CBT and dental treatment and rehabilitation) was delivered free of charge, therefore, appears to have been important for patients to be able to overcome their dental treatment difficulties. The availability of affordable treatment could play an important role in facilitating access to necessary dental treatment interventions for these patients.

Interdisciplinary CBT treatment was given. Due to limited resources, oral health care personnel are often required to provide anxiety treatment without access, or with limited access, to psychological expertise. The findings in this study suggest that mental health professionals could be a valuable allies for oral health care personnel.

The current case series study must be considered in light of several limitations. The small number of participants and the lack of a control condition makes it impossible to determine whether the findings are unique to TADA treatment and to evaluate the relative efficacy of the treatment received. The study also lacked a long-term follow-up assessment. Furthermore, some patients with dental fear have been subjected to torture [ 54 ]; however, such experiences were not reported by the current sample, making it difficult to generalize the findings to patients with a history of torture. The study also lacked information about substance abuse and previous negative experiences with dental care.

This study indicates that interdisciplinary CBT in the context of TADA teams could be both beneficial and acceptable for odontophobia and dental anxiety related to sexual abuse and violence. The results suggest that mental health professionals could be important allies for oral health professionals when caring for patients with severe dental anxiety and odontophobia. System-oriented interventions could benefit from interdisciplinary collaboration, striving to offer seamless and effective treatment options to vulnerable patient populations. A larger controlled study examining the long-term effects of TADA treatment is warranted.

Data availability

The anonymized datasets used during the current study are available from the corresponding author upon reasonable request.

Abbreviations

Cognitive-Behavioural Therapy

Torture, Abuse, and Dental Anxiety

Posttraumatic stress disorder

Mucosal and Plaque Score

Decayed, Missing, and Filled Teeth

The Modified Dental Anxiety Scale

Dental Fear Survey

Generalized Anxiety Disorder-7

Patient Health Questionnaire-9

PTSD Checklist for DSM-5

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Acknowledgements

The authors thank all the patients who participated in the study, the TADA dental nurses and all TADA dentist teams who participated in the data collection. They also thank Møre and Romsdal County Authority for the encouragement and support for conducting the study protocol.

Open access funding provided by NTNU Norwegian University of Science and Technology (incl St. Olavs Hospital - Trondheim University Hospital). The study and study protocol were founded by Møre and Romsdal County Authority.

Open access funding provided by NTNU Norwegian University of Science and Technology (incl St. Olavs Hospital - Trondheim University Hospital)

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Molde Competence Clinic for Public Dental Health Service, Møre and Romsdal County Authority, Molde, Norway

Yngvill Ane Stokke Westad, Gina Løge Flemmen, Stian Solem, Trine Monsen & Henriette Hollingen

Department of Psychology, Norwegian University of Science and Technology, Trondheim, Norway

Audun Havnen

Center for Oral Health Services and Research, Mid-Norway (TkMidt), Trondheim, Norway

Astrid Feuerherm

Nidaros Division of Psychiatry, Community Mental Health Centre, St. Olav’s University Hospital, Trondheim, Norway

Molde Hospital, Møre og Romsdal Hospital Trust, Molde, Norway

Kristen Hagen

Bergen Center for Brain Plasticity, Haukeland University Hospital, Bergen, Norway

Department of Mental Health, Norwegian University of Science and Technology, Trondheim, Norway

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YASW was responsible for data collection and drafting and revising the work.KH, SS and AH were responsible for the data analysis and interpretation. TM, GF, HH and AF, KH, SS and AH participated in the data collection, interpretation and/or revision process of the manuscript. All authors gave their final approval of the version to be published.

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Westad, Y.A.S., Flemmen, G.L., Solem, S. et al. Interdisciplinary CBT treatment for patients with odontophobia and dental anxiety related to psychological trauma experiences: a case series. BMC Psychiatry 24 , 606 (2024). https://doi.org/10.1186/s12888-024-06055-w

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Cognitive-Behavioral Therapy for a 9-Year-Old Girl With Disruptive Mood Dysregulation Disorder

Megan e. tudor.

1 Yale School of Medicine, New Haven, CT, USA

Karim Ibrahim

Emilie bertschinger, justyna piasecka, denis g. sukhodolsky.

Disruptive mood dysregulation disorder (DMDD) is a relatively new diagnosis in the field of childhood onset disorders. Characterized by both behavior and mood disruption, DMDD is a purportedly unique clinical presentation with few relevant treatment studies to date. The current case study presents the application of cognitive-behavioral therapy (CBT) for anger and aggression in a 9-year-old girl with DMDD, co-occurring attention deficit hyperactivity disorder (ADHD), and a history of unspecified anxiety disorder. At the time of intake evaluation, she demonstrated three to four temper outbursts and two to three episodes of aggressive behavior per week, in addition to prolonged displays of non-episodic irritability lasting hours or days at a time. A total of 12 CBT sessions were conducted over 12 weeks and 5 follow-up booster sessions were completed over a subsequent 3-month period. Irritability-related material was specially designed to target the DMDD clinical presentation. Post-treatment and 3-month follow-up assessments, including independent evaluation, demonstrated significant decreases in the target symptoms of anger, aggression, and irritability. Although the complexities of diagnosing and treating DMDD warrant extensive research inquiry, the current case study suggests CBT for anger and aggression as a viable treatment for affected youth.

1 Theoretical and Research Basis for Treatment

Anger, aggression, and irritability in youth are associated with various clinical diagnoses, including attention deficit hyperactivity disorder (ADHD), oppositional defiant disorder (ODD), and depression ( G. A. Carlson, Danzig, Dougherty, Bufferd, & Klein, 2016 ; Stringaris, 2011 ; Sukhodolsky, Smith, McCauley, Ibrahim, & Piasecka, 2016 ). A more recent diagnostic category now exists that also captures these symptoms: disruptive mood dysregulation disorder (DMDD; American Psychiatric Association [APA], 2013 ). DMDD is a childhood onset disorder characterized by at least three severe temper outbursts per week with distress that is disproportionate to emotional triggers. Furthermore, mood between these outbursts is disrupted, with children presenting as irritable or angry at least 50% of their waking hours. To meet criteria for the diagnosis, irritability symptoms should be present for at least 12 months without symptom-free intervals longer than 3 months. DMDD has significant overlap with symptoms of both disruptive behavior and mood disorders ( Dougherty et al., 2014 ; Mayes, Waxmonsky, Calhoun, & Bixler, 2016 ), leading to contention as to whether or not DMDD is truly a distinct diagnostic category ( Noller, 2016 ; Runions et al., 2016 ; Wakefield, 2013 ). Nevertheless, the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5 ; APA, 2013 ) includes DMDD as such ( APA, 2013 ; Roy, Lopes, & Klein, 2014 ), thus warranting further research on related assessment and treatment.

Children and adolescents with DMDD may benefit from behavioral interventions for anger and aggression. A large evidence base exists for cognitive-behavioral therapy (CBT) as a treatment for anger and aggression ( Sukhodolsky, Kassinove, & Gorman, 2004 ). Because anger outbursts, angry mood, and aggression are the core symptoms of DMDD, CBT may also be useful for children who meet diagnostic criteria for this newly characterized disorder.

Treatment studies related to DMDD are rare, despite converging evidence that DMDD may be common among clinic-referred youth ( Freeman, Youngstrom, Youngstrom, & Findling, 2016 ) and stable throughout childhood development ( Mayes et al., 2015 ). Two studies have demonstrated some effectiveness of treating concurrent ADHD and disruptive mood symptoms in children ( Baweja et al., 2016 ; Blader et al., 2016 ). One randomized controlled trial (RCT) to date has examined psychotherapeutic treatment effectiveness, specifically for youth with psychostimulant-medicated ADHD and an earlier diagnostic iteration of DMDD, known as severe mood dysregulation (SMD; Waxmonsky et al., 2015 ). The treatment program, ADHD plus Impairments in Mood (AIM), drew from extant CBT, behavioral parent training (BPT), and problem-solving models to target children’s awareness of and responses to mood dysregulation. Irritability symptoms were measured by the three items (temper loss, angry or sad mood, and hyperarousal) on two clinical parent interviews that focus on disruptive behaviors in children: the Washington University of St. Louis Kiddie Schedule for Affective Disorders and Schizophrenia (WASH-U-KSADS; Geller et al., 2001 ) and the Disruptive Behavior Disorders Structured Parent Interview (DBD-I; Hartung, McCarthy, Milich, & Martin, 2005 ). Disruptive behaviors were shown to significantly decrease in the experimental treatment versus an active control, whereas effects on the measured mood symptoms were not significant. Temper outbursts decreased during the course of treatment but were reported to substantially increase during treatment follow-up phase. Overall, the study indicates that behavioral interventions built from CBT and parent management training (PMT) principles may be helpful in youth with DMDD, though time-limited booster sessions may be warranted to maintain treatment benefits.

Many questions regarding the treatment of DMDD in children remain, especially in an individual therapy format. The present case study allows for an initial exploration of specially tailored CBT for anger and aggression ( Sukhodolsky & Scahill, 2012 ) as a viable treatment for a child with DMDD.

2 Case Introduction

“Bella” was a 9-year-old Hispanic girl whose mother enrolled her in our RCT for youth with anger and aggression ( Sukhodolsky, Vander Wyk et al., 2016 ). This ongoing RCT subscribes to a Research Domain Criteria (RDoC) approach by identifying dimensions of behavior and related neural markers that are not confined to specific diagnostic categories ( Cuthbert, 2014 ). Thus, Bella’s presentation of multiple diagnoses (explained below) complemented a trans-diagnostic approach to treating a broader spectrum of irritable behavior. Following assessment protocol, Bella was randomly assigned to CBT treatment (as opposed to supportive psychotherapy).

3 Presenting Complaints

Bella’s mother sought treatment due to increasing disruptive behaviors over the past year, including non-compliance at home and at school, physical aggression toward peers, and frequent behavioral meltdowns which resembled the temper tantrums of a much younger child. Tantrums included screaming, yelling, slamming doors, and crying. Triggers could include being asked to take her daily medication or feeling that someone was standing too close to her. Bella and her mother both noted that it was difficult for Bella to “move on” when something angered her. She also noted that Bella had an underlying irritable mood, manifesting as Bella appearing “cranky” the majority of the time and the family feeling they needed to “walk on eggshells” to avoid upset. Bella was at risk for suspension from her sports teams due to recurrent unprovoked aggression toward her teammates. At school, at least one phone call home per week was being placed due to Bella’s refusal to comply or sometimes to even speak to her teacher for days at a time. Bella and her mother noted that Bella was generally well liked by peers and teachers, given that she was hardworking and funny, yet her current disruptive behaviors were causing significant interference in making new friends and meeting academic goals.

Bella lived with her mother, stepfather, and three older siblings. She visited with her father who lived nearby approximately once per month. Bella’s mother denied any pre- or perinatal complications and stated that Bella met developmental milestones on time. Behavioral difficulties reportedly began around age 3, where Bella’s mother noted that she was extremely active and markedly stubborn. These concerns were exacerbated in the school setting and, by age 6, Bella participated in a pediatric evaluation that yielded a diagnosis of ADHD-Combined presentation due to ongoing difficulties with inattention and hyperactivity that were impeding her academic performance. Bella’s history was further complicated by persistent difficulties with math and related anxiety about math performance. These combinations of symptoms led to the provision of a school 504 plan that afforded Bella intensive math support, extra time on tests, and classroom breaks, as needed. At the time of intake, Bella was attending fourth grade in mainstream classes and described herself as doing well in school, save for assignments in math assignments which remained her least favored subject.

Bella had not participated in any form of psychological treatment prior to participating in our treatment study. Bella was prescribed Stratera (18 mg/day) at age 7 by her pediatrician, which was maintained at the time of our intake interview and throughout treatment. In our study, we include participants with either no medication or stable medication regimens, though medication management is not provided. Stratera is a brand name version of atomoxetine, a selective norepinephrine reuptake inhibitor. Although psychostimulant medication is generally recommended as the first-line treatment for ADHD in children ( Blader et al., 2016 ), there are sometimes reasons for prescribing alternative medications such as atomoxetine ( Pliszka, 2007 ). According to Bella’s mother, at age 7, Bella presented with mild anxiety, particularly related to school performance. Comorbid anxiety has been observed in 25% to 35% of children diagnosed with ADHD, and atomoxetine is accepted as effective with this dual diagnosis ( Hammerness, McCarthy, Mancuso, Gendron, & Geller, 2009 ). Overall, this relatively low dose of medication had reportedly proven useful in addressing both anxiety and ADHD symptoms for Bella and, according to our team’s psychiatry consultants, was appropriate for progressing with therapy without psychiatric re-evaluation.

Our study does not provide medication management or consultation regarding medication that children are receiving in the community. Children are eligible to participate if medication has been stable without plans for change for the 4-month study period. We generally only recommend psychiatric evaluation or re-evaluation for ADHD symptoms if these symptoms are clearly an underlying factor in the participant’s anger and aggression, or if symptoms grossly affect the participant’s ability to understand the material or engage in treatment. Neither of these descriptions applied to Bella, who met criteria for ADHD diagnosis based on clinical interview and was in the borderline clinical range on parent report measures ( T = 68 on the Attention Deficit/Hyperactivity subscale of the Child Behavior Checklist [CBCL]; Achenbach & Rescorla, 2001 ), but whose symptoms appeared relatively non-impairing at the time of intake.

5 Assessment

As part of the study, Bella and her mother were administered comprehensive assessments of irritability and associated psychopathology, including clinical interviews and parent report measures. With Bella’s assessment, we maintained adherence to the study protocol, which only required participation of one parent. However, we would have been happy to obtain information from Bella’s father or engage him in the study process if it had been requested by the family. In addition, Bella and her mother stated that behavior presentation was largely similar across the two households.

Diagnostic Interview

DSM-5 diagnoses were assigned based on the structured interview conducted by an experienced clinical psychologist (last author). The Kiddie Schedule for Affective Disorder and Schizophrenia for School-Age Children, Present and Lifetime (K-SADS-PL; Kaufman et al., 1997 ) is a diagnostic interview that assesses psychopathology in children based on child and parent report. Interview questions are presented to both children and parents separately, followed by integration of both informants’ report. DMDD symptoms were evaluated by the K-SADS addendum ( Leibenluft, 2011 ). DMDD symptoms are coded as “Not present,” “Sub-threshold,” or “Threshold” for DSM-5 diagnostic criteria. At the time of the interview, Bella’s prior diagnosis of ADHD-Combined presentation was confirmed due to impairing symptoms of inattention, distractibility, and hyperactivity, though these symptoms were reportedly significantly decreased and minimally impairing since medication prescription at age 7. Her preexisting community diagnosis of unspecified anxiety disorder was not confirmed with K-SADS; both Bella and her mother reported occasional bouts of worry about school performance but not to the frequency or intensity that warrants clinical diagnosis.

Per the K-SADS, Bella and her mother shared that Bella typically presented with out-of-control 30-min temper outbursts approximately 3 to 5 times per week. Outbursts consistently appeared out of proportion to the situation at hand and reportedly resembled that of a much younger child, around 3 to 4 years old. Outbursts consisted of screaming, crying, insulting others, and general non-compliance occurring at home and, less often, in the community (e.g., in the grocery store, at the sidelines of a soccer match). In between outbursts, Bella’s mood was described as generally “cranky” and her mother described feeling that she was “walking on eggshells” around Bella. Bella’s mother shared that this irritability occurred approximately 75% of the time, with Bella appearing neutral or cheerful the remaining 25% of each day. Bella’s persistently angry and irritable presentation was not only endorsed by her mother but also her elder siblings, teacher, and soccer coach. Opposition and defiance were noted since age 3; however, the outbursts and irritability described here had manifested for approximately 2 years preceding assessment (since age 7). The longest symptom-free period was as a few days, and such bouts were reportedly rare. Overall, symptoms were described as causing impairment for Bella in her family relationships, friendships, and school performance. The obtained symptom profile, in addition to the absence of past or current mania, warranted a diagnosis of DMDD. Of note, Bella also met criteria for ODD; however, a diagnosis of DMDD contraindicates ODD diagnosis ( APA, 2013 ).

Of note, we do not collect teacher ratings as part of study assessment procedure, although sometimes families bring copies of past assessments that include teacher ratings. However, in clinical settings, it is advisable to collect teacher ratings of ADHD as well as symptoms of other behavioral and mood disorders. For example, clinicians could seek out teacher report versions of the parent report measures described below, to then be integrated into the clinical assessment. Further information gathering can include discussion of core DMDD symptoms with teachers or other school professionals in order to better understand presentation of these symptoms across multiple settings.

Parent Report Measures

Bella’s mother filled out a battery of parent report measures. Scores on the measures of anger/irritability and aggression are presented in Table 1 . The 18-item CBCL–Aggressive Behavior subscale ( Achenbach & Rescorla, 2001 ) was completed as a “gold standard” measure of aggressive behavior and yielded a clinically elevated score for Bella. The Affective Reactivity Index (ARI; Stringaris et al., 2012 ) consists of seven items, six of which are averaged as an index of irritability. Youth with SMD were reported to have an average score of 7 on this measure. As such, Bella’s score of 10 reflected clinical elevation. The Disruptive Behavior Rating Scale (DBRS; Barkley, 1997 ) is an eight-item measure keyed to the DSM symptoms of ODD. A mean DBRS score of 12 and above indicates clinically significant symptoms, and Bella’s score of 13 was above this clinical threshold. Parent ratings of depression and anxiety conducted per the Child Depression Inventory ( Kovacs, 2011 ) and the Multidimensional Anxiety Scale for Children ( March, 2012 ) indicated that Bella was experiencing normative levels of internalizing symptoms. Together, these parent ratings indicated that Bella’s particular presentation of DMDD was characterized by externalizing behaviors and irritability, rather than depressive mood.

Pre-Treatment, Post-Treatment, and Follow-Up Assessments.

Note . MOAS = Modified Overt Aggression Scale; CGI-I = Clinical Global Impression–Improvement score (as compared with baseline functioning); CBCL = Child Behavior Checklist ( t scores); ARI = Affective Reactivity Index; DBRS = Disruptive Behavior Rating Scale.

Aggressive behavior was measured using the Modified Overt Aggression Scale (MOAS; Silver & Yudofsky, 1991 ; Yudofsky, Silver, Jackson, Endicott, & Williams, 1986 ) tailored to the assessment of aggression in clinical trials ( Blader, Schooler, Jensen, Pliszka, & Kafantaris, 2009 ). The MOAS was administered as an interview with the parent and child (separately) by an independent evaluator (licensed clinical social worker) who was not involved in treatment and was unaware of the treatment that Bella was receiving. The MOAS is used as a primary outcome measure in the relevant clinical trial ( Sukhodolsky, Vander Wyk et al., 2016 ) and consists of 16 items related to the aggressive behavior over the past week. Items are weighted based on potential harm and create four aggression subscales, including Verbal Aggression, Aggression Against Objects, Self-Directed Aggression, and Aggression Against Others. Bella evidenced significant levels of aggressive behaviors in all subscales excepting for self-directed aggression, resulting in an overall score of 32. For example, Bella was reported as presenting with three aggressive incidents (e.g., punching) toward non-relative peers in the week preceding evaluation.

Target Symptoms

In addition to the MOAS, the independent evaluator also elicited the two most pressing concerns in the area of anger and aggression and described these concerns, which are referred to as “target symptoms.” Target symptoms are coded in terms of frequency, duration, severity, and impact on adaptive functioning across all contexts ( McGuire et al., 2014 ). Bella’s target symptoms were (a) anger outbursts and meltdowns, characterized by verbal aggression and subsequent “shutting down,” with refusal to comply or communicate, and (b) physical aggression, such as hitting, punching, and shoving which most commonly occurred toward sports teammates, classmates, and her older brother.

Intellectual Functioning

Per study protocol, Bella completed the Wechsler Abbreviated Scale of Intelligence (WASI), indicating a verbal IQ of 93, a performance IQ of 99, and a full-scale IQ of 96. Overall, this intellectual functioning screener suggested that Bella’s intelligence was uniform across abilities and fell in the Average range of functioning. These results indicated that Bella would be a good candidate for the CBT content and activities ( Lickel, MacLean, Blakeley-Smith, & Hepburn, 2012 ).

6 Case Conceptualization

Bella, like many youth with ADHD, exhibited disruptive behavior concurrent with inattention and hyperactivity symptoms ( C. L. Carlson, Tamm, & Gaub, 1997 ). Although pharmacological treatment significantly decreased Bella’s school difficulties by age 7, anger and aggression persisted. Evidence suggests that children like Bella may possess an inherent predisposition for irritability, including impaired functioning in the amygdala and frontal lobe ( Vidal-Ribas, Brotman, Valdivieso, Leibenluft, & Stringaris, 2016 ). Her early onset of irritable behavior and aggression may have resulted in teachers and family members responding in an inadvertently reinforcing manner, for example, separating Bella from other children versus problem solving. Thus, Bella’s clinical profile reflected both a predisposition to disruptive behavior and an interaction with her environment that resulted in interference with developmental maturation of emotion regulation or social skills that were expected for her age. In addition to disruptive behaviors, Bella has also experienced some academic difficulties, particularly in the area of math. Academic performance became a source of anxiety which further compounded non-compliance with homework and behavioral problems at school. As such, Bella had learned from a young age to primarily communicate her negative emotions through avoidance, physical aggression, and tantrums, which were reinforced by Bella’s attainment of desired goals (e.g., a child going away or obeying her demands, family offering her several hours of personal space). Alone, these behaviors would have warranted a diagnosis of ODD. For Bella, however, her prolonged instances of angry and irritable mood in between temper outbursts indicated a diagnosis of DMDD. It is also important to note that early onset of ADHD and co-occurring symptoms of anxiety are also consistent with the diagnosis of DMDD ( Dougherty et al., 2014 ; Mulraney et al., 2015 ; Uran & Kılıç, 2015 ).

Although Bella demonstrated many strengths, such as athletic ability and sense of humor, many of her social experiences became overshadowed by negative interactions, which were interfering with her enjoyment of home and school life. As such, our treatment goal was to replace Bella’s maladaptive anger outbursts and aggressive behaviors with age-appropriate skills of managing frustration and communicating with others. Simultaneously, Bella’s mother was taught parenting tools for supporting Bella’s progress in learning of new emotion regulation and problem-solving skills.

7 Course of Treatment and Assessment of Progress

Bella and her mother were seen by a post-doctoral clinical psychologist (first author) for 12 weekly 60-min CBT sessions. Then, she participated in five booster sessions over the subsequent 3 months. Our program typically offers three booster sessions; however, additional booster sessions were requested by the family to maintain treatment gains. We agreed to provide extra boosters because in a recently published study of behavioral intervention for children with SMD, immediate irritability-related treatment gains were not maintained at 6-week follow-up ( Waxmonsky et al., 2015 ). Manualized CBT for anger and aggression in youth was administered using a structured treatment manual ( Sukhodolsky & Scahill, 2012 ). The treatment is organized into three modules: emotion regulation, social problem solving, and social skills.

After each session, children received a therapeutic homework, which is referred to as “anger management practice” with the child to avoid using the word homework . As part of this practice, children are asked to fill out an anger management log, different for each session, which asks for specific examples of using each skill discussed in the last session in the context of an angry or aggressive outburst, whether anger management strategies were implemented successfully or unsuccessfully. Completion of anger logs is rewarded at the next session with enthusiastic praise from the therapist and small prizes when developmentally appropriate. Parenting skills are also integrated into treatment and coached during additional parenting sessions.

The manual includes built-in flexibility features that allow the child and the therapist to select therapeutic techniques and activities that match the child’s developmental level and target symptoms. Additional material was integrated that focused on DMDD-specific symptoms (described further below). Progress was assessed through the battery of interview and parent report measures described previously, which were conducted before and after treatment, and following a 3-month “booster” phase. Treatment progress was also discussed at weekly check-ins with Bella’s mother about the form, frequency, duration, and intensity of Bella’s target symptoms (i.e., temper outbursts, physical aggression).

Emotion Regulation and Anger Management

Sessions 1 to 3 involved an introduction to therapy, psychoeducation, identification of anger triggers, and the development of strategies to prevent anger episodes, such as scripting verbal reminders and relaxation training. Bella responded well to this phase of treatment and was particularly impressed that there were alternative approaches to handling angry behaviors. She stated that she was unaware that anger could be changed. Bella’s anger triggers typically included the perception that peers or family members had wronged her and the desire to “teach them” it was not okay through yelling or aggression. For example, immediately preceding the first session, Bella had punched a basketball teammate for “putting her hands on” her. Bella’s mother confirmed that the girl had simply brushed against Bella while walking by her. Bella took to silently singing a popular song lyric, “Stop! Wait a minute!” in her mind when recognizing an anger cue or early signs of anger escalation (e.g., a 1 or a 2 on her 5-point anger thermometer), and then engaging in deep breathing or reciting verbal reminders to guide her behaviors, such as, “You are going to get in trouble” or “Maybe this isn’t something to get worked up over.” Each week, Bella earned small prizes (e.g., shopkins) for completing anger management practice logs that described her handling of an anger-provoking episode.

Social Problem Solving

Sessions 4 to 6 covered social problem-solving skills including problem identification, generating different solutions, and evaluating the possible consequences to reduce conflict. Identifying the differences between responses that are passive, assertive , or aggressive was especially useful in enhancing Bella’s ability to generating solutions to conflicts. The therapist helped Bella and her mother to collaborate on developing behavioral contracts to prevent specific conflicts at home. For instance, Bella initially presented with a 5- to 10-min anger outbursts approximately 5 times per week when asked to take her medication. This occurred despite the fact that Bella’s mother did not alter the request and, ultimately, Bella took her medication successfully each time. In treatment, Bella agreed to calmly and immediately take her medication each night and her mother agreed to take her to get doughnuts every Saturday based on that behavior. Subsequently, Bella’s tantrums regarding medication decreased to 0 within 2 weeks and maintained for the several subsequent months of treatment.

Bella also excelled at decreasing her hostile attribution bias by reframing her previously negative perceptions of others’ intentions. She recognized that many past incidents where she believed that people were attempting to bother or assault her were misunderstood. Bella showed pride in her new ways of handling these situations, making statements like, “People want to be my friend more now. They used to think I was cool but kind of crazy. Now they just think I am cool.”

Social Skills

Sessions 7 to 9 addressed social skills for preventing and resolving conflicts or anger-provoking situations with siblings, peers, teachers, and family. Potential solutions to conflicts were role-played in session, for example, acting out how to calmly handle disagreements with friends about what to play or how to politely ask her brother to stop teasing her. For example, when playing with others, Bella practiced asking for the opinions of her friends, like, “Would you all like to play it this way?” rather than insisting that they play her way at the beginning of a play session (e.g., “I’m in charge, I don’t care if you don’t like it”). These skills were practiced in session with her therapist playing the part of other children who may disagree, which was effective in escalating anger and allowing for practice of positive interactions. Monitoring of voice tone and facial expression was exercised through the use of video recording, thereby helping Bella monitor and modify her outward expression of anger. Bella agreed that these skills contributed to more positive play time and more fun with her friends, which she noted as a more important goal than getting her way.

Importantly, Bella practiced simply stating, “I need help” or “I need a break” when feeling upset, rather than using harsh words or physical aggression. Her teacher and family reinforced this effective communication by calmly and briefly discussing the situation at hand, problem solving, and allowing Bella some alone time, as needed. These communication skills were integral in decreasing aggression, as Bella felt that she had a new tool for resolving social problems that did not put her at risk for getting in trouble (unlike punching others).

Parent Training

Parents are an integral component in CBT for anger and aggression ( Sukhodolsky & Scahill, 2012 ). Three separate 60-min sessions were conducted with Bella’s mother to address family conflict and provide strategies for encouraging positive behaviors such as giving praise, attention, and privileges. This duration of sessions was sufficient with Bella’s treatment, although more flexibility may be required in other cases. The treatment manual suggests conducting parent sessions in conjunction with the first, middle, and final CBT sessions, though flexible administration is often required due to family scheduling needs and to ensure that parent training coincides effectively with CBT sessions. Treatment progress and skills covered in each CBT session were also reviewed with the parent at each visit so that parents could track and reward application of new anger management skills at home. These parenting skills were especially important to Bella’s progress, given that she was growing up in a household with multiple siblings and expected behaviors often went unnoticed, whereas misbehavior resulted in one-on-one attention. In parenting sessions, the converse response was practiced with Bella’s mother, wherein “shut down mode” or yelling received no attention, whereas Bella’s problem solving and use of other coping strategies received praise and encouragement.

School Consultation

To maximize treatment gains in the school setting, Bella’s therapist had intermittent phone conversations with Bella’s fourth-grade schoolteacher. Target behaviors (e.g., decreasing aggression, increasing compliance) and related strategies (e.g., Bella’s recognition of anger cues, practicing effective communication in place of aggression) were relayed to Bella’s teacher, who was eager to encourage Bella’s progress in the school setting through prompting and praise. Bella’s teacher provided invaluable insight into behavioral progress, including report that Bella’s decrease in irritable behaviors made her more amenable to math tutoring. Subsequently, Bella arrived to several sessions sharing about success with math during the previous week.

Adapting Treatment for DMDD

Although much of the extant CBT treatment manual was appropriate for addressing Bella’s target behaviors of aggression and tantrums, some specialized material was integrated into Bella’s care to target the prolonged periods of irritability she demonstrated at home, school, and, sometimes, in the therapy session. These adaptations included (a) extending psychoeducation, (b) emphasizing on behavioral activation, (c) building an emotion regulation template for reducing duration of irritable mood periods, and (d) including extra booster sessions during the 3-month booster period (five instead of the usual three sessions). Psychoeducation included characteristics of prolonged irritable episodes, such as specific triggers, the common feeling of being “stuck” in that mood, and creating a creative metaphor for the irritable mood. Bella described her prolonged irritable episodes as “shut down mode” wherein her brain withdrew and could only react “in a snappy way” toward others. This allowed Bella to quickly identify irritability and remind herself that it was possible to coach her brain to “reverse shut down mode” where she could enjoy herself and interactions with others.

Behavioral activation was used to reduce prolonged periods of negative mood (e.g., Pass, Whitney, & Reynolds, 2016 ). Specifically, Bella maintained a list of enjoyable activities she could do in any setting to help herself keep active and busy, which, in turn, reduced the intensity of her “shut down mode” and increased her chances of being happy. For example, she would read, watch television, or ask family members to play with her during these instances. Prior to treatment, when in “shut down mode,” she was most likely to retreat to her room and dwell on the situation that triggered her anger.

Last, although decreasing irritability was an important goal, it was also recognized that some occasional irritable mood is typical, especially after a child is particularly disappointed or frustrated. As such, Bella and her mother collaborated with the therapist to identify a goal for the form and duration of irritable behavior. Specifically, Bella decided that 20 min of alone time, which she would request of her family calmly, would be sufficient to take part in a fun activity and help her “move on,” to which her mother agreed. These skills were especially relevant during the booster sessions of therapy, likely because tantrums and aggression had significantly decreased and “shut down mode” became a more pressing behavioral concern.

Post-Treatment Assessments

All outcome data are presented in Table 1 . Bella’s improvement was assessed following 12 sessions of CBT (and also at follow-up, presented in the “Follow-Up” section below). All post-treatment measures indicated a significant decrease in anger/irritability and aggression and fell within the normative range of functioning.

MOAS score reduced from 32 to 2, demonstrating that Bella had exhibited zero instances of verbal or physical aggression in the past week, and only one instance involving property damage: slamming a door when asked to clean her room before watching a movie. At that time, her mother noted that “shutting down” occurred once during the past week and was disruptive to family activities. As such, this behavior was targeted in later booster sessions.

The independent evaluator assigned a Clinical Global Impression-Improvement (CGI-I) score as a primary categorical outcome measure in the present research study ( Arnold et al., 2003 ). This score indicates the level of behavioral change from baseline rated on a 7-point scale (1 = very much improved ; 7 = very much worse ). Bella’s target symptoms of decreasing meltdowns and decreasing physical aggression were rated as 1 “ very much improved .”

8 Complicating Factors

Bella’s irritability served as a mildly complicating factor in two treatment sessions (Session 5 and a booster session). Specifically, irritability and opposition presented to a degree that limited Bella’s engagement in session material. In both occurrences, Bella was angered by something that occurred prior to session and initially refused to speak to her therapist. Although these instances were challenging in terms of completing planned session material, they were recognized as inherent to Bella’s target symptoms and, ultimately, helpful in exercising in-vivo practice of emotion regulation skills. Fortunately, Bella and her therapist were always able to end these sessions on a positive and meaningful note by offering validation and clear contingencies that both modeled and rewarded behavior activation (e.g., “I’m sorry to see you are having a rough day, Bella. When you are ready to talk, let me know. I want to ask you one question about the past week and then I have a very funny video to show you!”). These potentially complicating factors are especially important for the consideration of students and professionals, and are addressed further in “Recommendations to Clinicians and Students” section.

9 Access and Barriers to Care

It is important to note that the current treatment was conducted as part of a research study and, thus, may not reflect the typical clinic environment. As part of the study, the family received free clinical services, monetary compensation for their time, and flexible scheduling options. These characteristics of the study likely lessened the burden of participation for the family, who did not report any significant difficulties with completing all study visits. A family of a child referred to an outpatient clinic for a similar treatment would be responsible for the treatment cost, without compensation for time dedicated to assessment and treatment, which could limit some families’ ability to access and complete treatment.

10 Follow-Up

Bella participated in five booster sessions over the course of 3 months, immediately following the completion of the standard 12 CBT sessions offered as part of our research study. These sessions were designed to review and reinforce the content of the therapy program and to identify ongoing areas of need. These sessions are administered once per month on average, although in Bella’s case, we added two additional sessions to address DMDD symptoms. In Bella’s case, these boosters were useful for check-ins regarding irritability and behavioral activation skills, which were relevant to the remaining behavioral goals at that time. Our study typically offers three booster sessions for families but, given past evidence that suggests the utility of follow-up sessions for youth with DMDD ( Waxmonsky et al., 2015 ), two additional sessions appeared appropriate. Bella and her mother noted that these sessions were helpful at maintaining progress and continuing to target irritability goals. This report was supported by the follow-up data that were consistent with data collected post treatment (see Table 1 ). During the week preceding follow-up assessment, she was reported to have slammed a door three times when frustrated by homework assignments related to math. No instances of “shut down” were reported.

Following study completion, the family was encouraged to seek out consultation from the team should any concerns arise regarding Bella’s behavior management. No such requests have been made (4 months post study at the time of manuscript preparation).

11 Treatment Implications of the Case

The current case demonstrates the feasibility of CBT for anger and aggression in children with DMDD. No existing studies have examined individually administered CBT for anger and aggression in youth with DMDD, though the need thereof is increasingly important as this new diagnosis gains clinical attention ( Leibenluft, 2011 ; Roy et al., 2014 ). Our current case study shows how a child with DMDD can be effectively treated with a structured CBT for anger and aggression treatment ( Sukhodolsky & Scahill, 2012 ) enhanced with psychoeducation and behavioral activation strategies ( Hopko, Lejuez, Ruggiero, & Eifert, 2003 ). The enhancements to the CBT program may have been especially important to Bella’s excellent response to treatment. The five booster sessions allowed for a more gradual transition out of therapy and focused on decreasing non-episodic irritability, which may have been key to her long-term progress. These results are in contrast to previous findings that treatment gains were not maintained 3 months after group therapy for SMD ( Waxmonsky et al., 2015 ).

Notably, Bella was a participant in our ongoing randomized controlled study that tests the utility of CBT for irritability in children across diagnostic categories. This study is based on the RDoC initiative ( National Institutes of Mental Health, 2016 ) that aims to explore the core dimensions of psychopathology based on neurobiology and behavior, as opposed to the traditional categorical approach to diagnosis. Ultimately, RDoC attempts to integrate findings in genetics, neurology, molecular biology, cognitive science, and other disciplines to better inform our diagnostic classification system. The Negative Valence System, one of the five RDoC domains, encapsulates anger and aggression—the variables targeted in Bella’s treatment. Applying a treatment for a core symptom area (anger and aggression) rather than a specific diagnosis may have been ideal in treating Bella. Given DMDD’s high co-morbidity with other DSM diagnoses, including ADHD, and its significant overlap with ODD and depression, treatment of a specific categorical diagnosis would be challenging and likely misguided. In addition, almost all childhood psychiatric diagnoses are associated with increased risk of aggression ( Jensen et al., 2007 ). If a treatment such as CBT for anger and aggression can be implemented successfully across diagnostic categories, it may decrease the need for diagnostic precision in an imperfect system such as the DSM-5 . The current case study indicates that this singular treatment may be applied and/or modified to effectively treat a core symptom area in children that meets criteria for various DSM-5 disorders. It will be especially useful to identify other treatment packages that may be applied trans-diagnostically, especially for commonly co-occurring disorders in youth.

A benefit of the current treatment may be the ease of implementation across professionals. Bella’s provider possessed a PhD in clinical psychology, whereas other clinicians in our current study are psychology graduate students and child and adolescent psychiatry fellows. This flexibility in implementation may be particularly relevant for treatment of children with DMDD who may present with psychiatry referrals. Potential psychopharmacologic treatments for DMDD that have been suggested might include antidepressants, mood stabilizers, stimulants, and antipsychotics ( Tourian et al., 2015 ); however, medication alone may not be ideal. Medications, of course, are not without side effects, many of them significant and/or requiring regular monitoring over the course of treatment, including with blood work. In addition, given that there are two distinct symptoms clusters being treated in DMDD—irritable or depressed mood and angry outbursts—it is reasonable to conclude that in many cases, more than one medication might be required to treat symptoms. Our CBT program with some modification appears to be effective in treating DMDD over a short period of time with minimal modifications and, as such, may be ideal for first-line treatment for youth DMDD, particularly those who present with irritable mood in between outbursts.

Bella’s presentation did not reflect the symptom profile of some other youth DMDD. Namely, while she experienced significant and impairing irritability, she did not experience depressive symptoms such as withdrawal, anhedonia, or suicidal ideation. Therefore, the treatment implications of the current case are cautioned in terms of application to youth experiencing depressive mood between anger outbursts, wherein additional or different modifications would likely be warranted for treatment results and, above all, patient safety. It is of interest to note that behavioral but not mood symptom changes were an outcome of group therapy for SMD ( Waxmonsky et al., 2015 ), which further speaks to the complex nature of treating the co-occurring symptoms captured by DMDD. Furthermore, the same must be stated in reference to anxiety symptoms, which commonly co-occur with DMDD but were not endorsed for Bella. Youth with DMDD and significant anxiety may benefit from additional anxiety-focused behavioral interventions (i.e., exposure and response prevention).

Another caution toward the current results is the fact that Bella was receiving medication for ADHD and mild anxiety. The medication was stable during the study, and it is unknown what effect the treatment would have had in a child with the same diagnostic profile without medication. Lastly, the fact that the current case study focuses on a female is not to be overlooked. Like all disruptive behavioral disorders, early evidence suggests that females may be less likely to be given a diagnosis of DMDD ( Dougherty et al., 2014 ; Tufan et al., 2016 ). We are glad to provide evidence of treatment utility with a female patient, given that they may be less likely to be featured in this area of child psychology, though further study of treatment implications as they differ (or do not differ) across the sexes is warranted.

12 Recommendations to Clinicians and Students

Although we have previously stated that CBT for anger and aggression can be delivered by a range of clinicians, it is important that clinicians feel familiar and competent with delivering the complete manual prior to starting treatment. The modules reflect a variety of themes and strategies that may be useful to children; however, a high degree of flexibility is recommended ( Kendall & Beidas, 2007 ). For example, it can be useful to improvise and incorporate material from later sessions if that material is pertinent to a child’s presenting complaint on a given day. Furthermore, some children may dislike particular strategies (e.g., deep breathing), and it is significantly more important to maintain a strong therapeutic alliance by collaborating on goals and strategies than it is to achieve 100% fidelity for every session. In fact, as part of our current research study, an 80% fidelity rating is encouraged.

In addition, children with DMDD can be difficult to engage with due to both their baseline anger and irritability, as well as recurrent temper outbursts or meltdowns. It is likely that the clinician will experience at least one disruptive behavior episode (or many more) during session. These incidents are par for the course and, perhaps in a counterintuitive manner, are extremely beneficial to the child’s progress in treatment. Specifically, therapists are able to demonstrate appropriate behavioral contingencies and extinction schedules that will be useful for parents to observe. Bella, for example, once came to session angry at her sister and refused to speak to her therapist. The therapist use the opportunity to remind Bella of the skills she could apply to “turn it around” and checked in with Bella’s mother until Bella was observed putting effort into that goal (i.e., taking deep breaths, attempting to join the conversation), at which time she was praised and given a choice of a fun activity. Thus, Bella’s mother was able to observe selective attention, which can be a particularly difficult parenting skill for parents of children with disruptive behavior, and Bella was able to practice skills with the direct support of her clinician. We encourage clinicians and students not to dread disruptive behavior in session, but rather to welcome it as a unique and effective learning opportunity. However, clinicians must, of course, have a sound understanding of behavioral intervention to successfully respond to such incidents.

As with any type of behavioral modification, progress can be quite gradual. It may take several sessions before the child “buys in” to the treatment. It can be helpful to frame the treatment in terms of tangible benefits for the child; there is often a noticeable switch where the child recognizes that decreasing anger and aggression leads to specific and appreciable outcomes. For example, most children will recognize that hitting a peer will make that peer less likely to play with them in the future, even if they feel that the peer “deserves it,” or that insulting a teacher will lead to them getting detention even if they feel it is “unfair.” It is important to remember that these children often have a long history of feeling that they are “bad,” and an integral component of treatment is to counter this belief. A strong rapport can be built in the first session, simply by validating the child’s point of view and listening to recent difficulties without criticism. It is often helpful to alert the children that nothing shared in session will get them into trouble and, in fact, that the goal of therapy is to help them get in trouble less and enjoy their day-to-day life more. Ultimately, it is ideal for the child to recognize how their behavioral change will benefit them in their day-to-day life, which usually leads to them feeling proud about their efforts and accomplishments.

The parent check-ins at the end of each session are crucial to the success of the therapy. As outlined in the manual, be sure to stress to the parents during the first session how important it is to consistently praise positive behavior and to “catch the child being good.” At each parent check-in, the parent should provide a concrete example to the clinician of the child engaging in a positive behavior or attempting to apply skills and tools learned during the previous CBT session. Due to the “review” nature of these check-ins, a notable risk is present that the parent and/or child will attempt to use the time to simply list complaints about the past week, which is counterproductive to long-term progress. As such, clinicians should troubleshoot specific concerns and integrate them into session material (e.g., problem solving) but should also assertively request “highlights” of the past week. In addition, it can be helpful to supplement the three parent sessions and parent check-ins with concepts and tools from Parent Management Training, including structured behavior plans for the home. The clinician should also remind parents that the goal of treatment is not 100% remission. Occasional outbursts are a normal part of development and are not always pathological. It is best to frame the child’s success in terms of a decrease in the frequency and intensity of the target symptoms that were defined at the beginning of the treatment.

It is also important to point out to clinicians and students that the study of treatment for DMDD is new. Here, we present the results of an extant treatment that was adapted for a child with DMDD. It would be remiss for us to imply that this may be the only viable treatment for youth with DMDD, though it is difficult to expound upon treatment alternatives. Nevertheless, as mentioned previously, DMDD overlaps with other diagnostic categories that have long-standing evidence for the utility of cognitive (e.g., Boxer & Butkus, 2005 ), behavioral (e.g., Folino, Ducharme, & Conn, 2008 ; Rote & Dunstan, 2011 ), and combined (e.g., Pass et al., 2016 ) approaches to treatment. We are not currently aware of an evidence-based psychotherapeutic approach that would be definitively distinct from the CBT treatment presented here.

Last, as shown in the current case, these youth are likely to present with a complex history and multiple diagnoses, including ADHD and internalizing disorders. Thus, it is important for clinicians and students working with these youth to be well versed in a variety of clinical presentations, as well as related behavioral and pharmacological treatments. Furthermore, in the age of RDoC, clinical training will likely benefit from integrating behavioral treatments for core symptoms—such as anger and aggression. Such a training priority may help to serve a larger population of youth, including those with more complex clinical presentations such as DMDD.

Acknowledgments

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study is supported by National Institute of Mental Health (Grant/Award Number “R01 MH101514” to Drs. Denis Sukhodolsky and Kevin Pelphrey).

Biographies

Megan E. Tudor , PhD, is a postdoctoral associate at the Yale Child Study Center where she conducts clinical research, including diagnostic assessment and therapy for research participants. Her research interests relate to imporoving clinical services for youth with a variety of neurodevelopmental and behavioral disorders, as well as their family members.

Karim Ibrahim , MS, is a former trainee of the Yale Child Study Center where his focus was on behavioral interventions for autism and disruptive behavior disorders. He is a doctoral candidate in clinical psychology at the University of Hartford.

Emilie Bertschinger , BA, is a post-graduate associate at the Yale Child Study Center. She completed her bachelor’s in psychology at Boston University in 2015. She coordinates the clinical research study described in the current case study.

Justyna Pasecka , MD, is a fellow in the Solnit Integrated Training Program in Adult and Child Psychiatry at the Yale Child Study Center. She will complete her training in 2017 and will continue providing clinical services with children and adolescents.

Denis G. Sukhodolsky , PhD, is an associate professor and director of the Evidence-Based Practice Unit at the Yale Child Study Center. His lab conducts research on the efficacy and mechanisms of behavioral treatmetns for children with neurodevelopmental disorders such as autism spectrum disorder, Tourette syndrome, OCD, anxiety, and disruptive behavior disorder.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

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