Grand Rounds Case Study: Stacey

Grand Rounds Case Study: Stacey. A brain with words in it Description automatically generated.

General Overview. Children and Physical Abuse | Child ....

Relevant Terms. Post-Traumatic Stress Disorder (PTSD): A psychiatric disorder caused by exposure to a traumatic event that includes symptoms like hypervigilance, avoidance, and unwanted thoughts (Di Tella et al., 2022). Hypervigilance: A heightened sense of danger, which may be observed in patients with PTSD due to trauma (Di Tella et al., 2022). Avoidance: Attempts to keep away from thoughts, feelings, or things that remind one of the trauma, an indicator of PTSD (Di Tella et al., 2022)..

Relevant Terms. Dependent Personality Disorder (DPD): A personality disorder that is defined by the patient’s dependence on others, submission, and fear of being left alone (Liang, 2022). Submissive Behavior: Overly compliant and passive actions, driven by a need to avoid conflict and maintain relationships, common in DPD (Liang, 2022). Learned Helplessness: A psychological state in which people become helpless after being exposed to situations beyond their control and may become passive (Marx et al., 2023)..

Core Challenges in Stacey’s Case. Trauma Impact: Stacey suffers from severe social anxiety, which makes her avoid situations that may involve interaction with other people (Di Tella et al., 2022). These symptoms disrupt her ability to function socially and professionally. Dependency: Stacey relies heavily on her friend Corey for emotional and practical support, displaying traits consistent with Dependent Personality Disorder (Liang, 2022). Her dependency limits her autonomy and reinforces learned helplessness. Low Self-Esteem: Persistent feelings of inadequacy and guilt stemming from childhood abuse. These feelings align with Major Depressive Disorder (Marx et al., 2023)..

Diagnostic Challenges. Overlap in Symptoms: PTSD, DPD, and MDD share overlapping symptoms such as feelings of helplessness, guilt, and avoidance (Di Tella et al., 2022; Liang, 2022). This overlap complicates the identification of primary issues. Risks of Misdiagnosis: Mislabeling dependency as DPD without considering trauma may lead to ineffective interventions (Marx et al., 2023). Incorrect diagnoses can result in stigma, hindering Stacey’s recovery and reducing treatment efficacy..

Problems Rooted in Trauma. Emotional and Physical Abuse During Childhood Stacey was subjected to severe physical and emotional abuse from her father, including frequent intimidation and threats to maintain secrecy about the family’s dysfunction (Grand Rounds Case Study, 2023). She was taught from an early age to suppress her feelings and remain silent, which created internalized shame and guilt. Physical discipline in the household was harsh and left Stacey feeling powerless, perpetuating fear and insecurity. The emotional abuse included verbal put-downs and invalidation, further undermining her sense of self-worth. Authoritarian Parenting and Lack of Emotional Safety Stacey’s father operated with an authoritarian parenting style, demanding strict obedience and suppressing dissent or individual expression. Any attempt to express herself or seek attention was met with punishment or ridicule, teaching Stacey to suppress her emotions. Her mother, though present, remained passive and failed to provide emotional support or advocate for Stacey against her father’s authoritarian control. This lack of emotional safety during her formative years left Stacey without the tools to navigate relationships or trust others..

Dependency and Self-Worth Issues. Emotional Reliance on Corey Stacey relies heavily on Corey, a fellow survivor of domestic violence, to validate her decisions and provide emotional support (Grand Rounds Case Study, 2023). She struggles to function independently, seeking Corey’s approval and encouragement for even minor decisions, such as pursuing education or managing daily activities. Corey acts as Stacey’s primary support system, which while helpful in the short term, reinforces Stacey’s dependency and limits her autonomy. Stacey fears losing Corey’s support, which intensifies her reluctance to assert her independence. Dependency Schema from Unmet Emotional Needs in Childhood Stacey’s childhood neglect created a dependency schema, where she learned to rely on external figures for stability and emotional regulation. The lack of consistent nurturing from her parents left her feeling incapable of managing life’s challenges on her own. Her learned helplessness is rooted in her belief that she is inherently weak and requires someone else to “save” her..

Symptoms and Everyday Impact. Social Phobia and Workplace Difficulties In the workplace, fearing ridicule or exclusion, she cannot express herself when interacting with co-workers, which hampers her working experience. This also includes shopping for basic needs such as food; she gets scared and alert, which makes her ignore errands or drag Corey along. These behaviors prevent her from building healthy relationships and, thus, worsen her feelings of loneliness. Avoidance of Independence, Reinforcing Helplessness Stacey does not take chances to become independent, for instance, in seeking her own house or enrolling in college courses, without being prompted to do so. This is because she feels that she can only succeed with the help of someone else and thus continues in a cycle of dependency. She continues to delegate the decision-making authority to Corey or any other person she feels is better positioned to make decisions, thus strengthening her feeling of being powerless..

Role of Family Dynamics. Dysfunctional Family System: Authoritarian Father, Passive Mother Stacey’s father was a dictator at home, and he controlled the family with fear and violence to ensure that they did not defy his authority. He discouraged Stacey from talking to anyone, expressing feelings, or asking for help, thus cutting her off from other people who might have been able to help her. Her mother, who was physically present, had a passive role and did not intervene or support Stacey, leaving her without a motherly figure. The family values focused on submission and discipline rather than independence and self-actualization, hampered Stacey’s personal growth. Intergenerational Patterns of Control and Silence Stacey’s family had the characteristics of intergenerational transmission of dysfunction, in which control and emotional numbing were transferred across generations. This rather strict structure did not allow for questioning authority or establishing personal boundaries, which Stacey transferred into her adult relationships. These dynamics shaped Stacey’s view of looking for the needs of others and neglecting her own, which led to her submissive behavior and her inability to stand up for herself..

Mental Health Exam Findings. Childhood Trauma: Violence and intimidation by her father resulted in her experiencing chronic fear, guilt, and shame. Social Challenges: She avoided social situations, including work and other public places, because of fear. Initial Progress: Greater confidence at work and a better friendship with Corey. Empowerment: These included the process of moving towards an independent lifestyle, for instance, enrolling for college classes and applying for an apartment. Critical Statement: “I am just not going to worry about the guilt and just erase it—I have to do what I must.”.

DSM-5 Diagnoses for Stacey. PTSD (Post-Traumatic Stress Disorder) Symptoms (as per DSM-5): Hypervigilance Intrusive Thoughts/Flashbacks Avoidance Negative Mood Sleep Disturbances MDD (Major Depressive Disorder) Depressed Mood Loss of Interest or Pleasure Worthlessness or Guilt Fatigue or Loss of Energy Cognitive Impairments DPD (Dependent Personality Disorder) Symptoms (as per DSM-5): Excessive Reliance on Others Fear of Disagreement or Rejection Clingy Behavior Difficulty Making Decisions Independently Fear of Abandonment Symptoms (as per DSM-5):.

Assessment and Intervention Concerns. Accuracy: Are the current observations revealing Stacey’s true patterns of behavior and emotional responses, or are there underlying issues that need further exploration? Prejudice: Risk of over-labeling or bias in diagnosing, particularly when symptoms overlap (e.g., PTSD, MDD, DPD), potentially hindering treatment effectiveness. Process: Assessment should be dynamic, requiring ongoing adjustments as Stacey progresses in therapy and as new information emerges about her experiences and symptoms. Diagnosis Cautions: Be cautious of misdiagnosis or stigmatization, as labeling Stacey with certain disorders may influence how she perceives herself and affect her treatment outcomes..

Setting Assessment-Informed Goals. Goals: Develop healthy, autonomous relationships, reducing reliance on others for emotional and practical support. Strengthen independence, encouraging Stacey to make decisions and engage in life activities without excessive reassurance from others. Resources: Support groups, vocational counseling. Referrals: Trauma-informed care specialists and financial advisors..

Evidence-Based Treatments. Effectiveness: Peters et al. (2021) demonstrated that Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) effectively reduces trauma symptoms and avoidance behaviors in individuals with PTSD. Approaches: Cognitive Restructuring: Helps clients challenge and change negative thought patterns related to the trauma. Exposure Therapy: Gradual, controlled exposure to trauma-related memories and situations to reduce avoidance and anxiety..

Evidence for Schema Therapy. Effectiveness: Peeters et al. (2022) found that Schema Therapy (ST) is highly effective in treating dependent personality disorder (DPD) and other maladaptive schemas by addressing deep-seated negative beliefs. Results: Improved Autonomy: Clients report better self-reliance and reduced dependency on others for emotional and decision-making support. Reduced Dependency: ST helps individuals break free from dependency schemas, fostering healthier and more autonomous behaviors..

Evidence for Dialectical Behavior Therapy. Effectiveness: Vogel et al. (2021) supported the use of Dialectical Behavior Therapy (DBT) in trauma cases, particularly for improving emotional regulation and managing intense emotional reactions. Focus Areas: Skill-Building in Distress Tolerance: Helps individuals manage overwhelming emotions and stress without resorting to avoidance or unhealthy coping mechanisms. Interpersonal Effectiveness: Teaches skills to improve relationships, assert boundaries, and communicate needs effectively, essential for individuals with trauma-related dependency issues..

Application of Therapies. Reprocessing Trauma-Related Memories: TF-CBT can help Stacey confront and reprocess the traumatic memories from her childhood abuse, reducing the emotional charge attached to these memories. This process can allow Stacey to integrate the trauma more healthily, reducing her current avoidance behaviors and hypervigilance. Cognitive Restructuring of Guilt and Shame: TF-CBT will focus on challenging the deep-seated feelings of guilt and shame Stacey carries from her childhood experiences. Cognitive restructuring can help her identify distorted thoughts (e.g., "I'm to blame for what happened") and replace them with healthier, more balanced beliefs..

Strengths and Limitations. Strengths: Short-Term Effectiveness: TF-CBT is evidence-based and typically effective in reducing trauma-related symptoms in a relatively short period (12-16 weeks). Structured and Goal-Oriented: The therapy's structured approach allows Stacey to track her progress and build coping skills in manageable steps. Limitations: Initial Resistance to Confronting Trauma: Stacey may resist directly confronting her trauma, which can hinder the effectiveness of the therapy early on. Emotional Intensity: Confronting painful memories may temporarily increase distress before improvement..

Application of Schema Therapy to Stacey’s Case. Addressing Abandonment and Dependency Schemas: Schema Therapy will focus on Stacey’s deep-rooted beliefs about abandonment and dependency that were formed during her childhood neglect. The therapy will help her challenge these beliefs and build healthier attachments and self-reliance. Limited Reparenting for Corrective Experiences: Limited reparenting will provide Stacey with corrective emotional experiences, where the therapist serves as a compassionate and validating figure. This can help Stacey develop a more secure sense of self and learn healthier ways of relating to others..

Strengths and Limitations of Schema Therapy. Strengths: Long-Term Improvement: Schema Therapy is designed for long-term changes, focusing on the root causes of dependency, low self-worth, and maladaptive behavior. Addressing Core Beliefs: It helps clients like Stacey reframe long-standing negative core beliefs that drive unhealthy behaviors and relationship patterns. Limitations: Requires Extended Intervention: The therapy is intensive and may require longer treatment periods (28 sessions or more), which could be challenging for Stacey’s emotional endurance. Potential for Emotional Overwhelm: Given the depth of work required, Stacey may experience emotional overload as she addresses these deeply ingrained schemas..

Application of DBT to Stacey’s Case. Emotional Regulation for Guilt and Self-Criticism: DBT will help Stacey develop skills for managing intense emotions like guilt and self-criticism, reducing the impact of these feelings on her daily functioning. Emotion regulation techniques will enable her to identify, label, and tolerate difficult emotions, improving her overall emotional stability. Building Interpersonal Skills for Autonomy: DBT will teach Stacey effective communication and interpersonal skills to improve her relationships and assert her needs. As a result, Stacey can work toward greater autonomy and independence, reducing her reliance on others like Corey for emotional validation..

Strengths and Limitations of DBT. Strengths: Practical Skill-Building: DBT’s focus on concrete skills, such as distress tolerance and emotion regulation, can provide Stacey with immediate tools to cope with everyday challenges. Adaptability: DBT is flexible and can be tailored to Stacey’s specific needs, particularly in addressing trauma-related emotional dysregulation. Limitations: Time-Intensive Learning Process: DBT requires significant time and effort to master its skills, which may overwhelm Stacey as she learns to implement them in her life. Commitment to Change: Success in DBT requires consistent practice and commitment, and Stacey may struggle with the regularity and intensity of the practice required..

Multi-Phase Treatment Plan. Phase 1 TF-CBT for Trauma Relief Address hypervigilance, intrusive memories, and avoidance behaviors stemming from past abuse. Phase 2 Schema Therapy for Dependency and Core Beliefs Address Stacey’s dependency on others and work to challenge and change maladaptive schemas, such as abandonment and worthlessness. Implement limited reparenting to provide corrective emotional experiences and help Stacey build a more secure sense of self. Phase 3 DBT for Emotional Regulation and Independence Develop skills for managing intense emotions, such as guilt and self-criticism..

Conclusion. Stacey requires a comprehensive approach to address her PTSD, dependency, and low self-esteem. The multi-phase treatment plan integrates TF-CBT, Schema Therapy, and DBT to provide trauma relief, challenge core beliefs, and build practical skills for independence. A personalized approach ensures that each therapy targets specific aspects of Stacey’s challenges. Combining evidence-based practices allows for immediate symptom relief and long-term emotional resilience and autonomy..

Questions for Class Discussion. Diagnostic Challenges: How can we distinguish between dependency stemming from trauma (PTSD) and dependency related to Dependent Personality Disorder (DPD)? Are there risks of over-diagnosis or misdiagnosis that could impact treatment outcomes? Balancing Short-Term and Long-Term Goals: How can therapy address Stacey’s immediate symptoms while fostering long-term independence? What strategies might help prevent dependency on the therapeutic process itself?.

References. Di Tella, M., Romeo, A., Zara, G., Castelli, L., & Settanni, M. (2022). The post-traumatic stress disorder checklist for DSM-5: psychometric properties of the Italian version. International Journal of Environmental Research and Public Health, 19(9), 5282. https://doi.org/10.3390/ijerph19095282 Liang, W. (2022, June). How Does Dependent Personality Disorder Form, Develop, and Affect Human Life? In 2022 8th International Conference on Humanities and Social Science Research (ICHSSR 2022) (pp. 1756-1760). Atlantis Press. https://doi.org/10.2991/assehr.k.220504.318 Marx, W., Penninx, B. W., Solmi, M., Furukawa, T. A., Firth, J., Carvalho, A. F., & Berk, M. (2023). Major depressive disorder. Nature Reviews Disease Primers, 9(1), 44. https://doi.org/10.1038/s41572-023-00454-1 Peeters, N., Van Passel, B., & Krans, J. (2022). The effectiveness of schema therapy for patients with anxiety disorders, OCD, or PTSD: A systematic review and research agenda. British Journal of Clinical Psychology, 61(3), 579-597. https://doi.org/10.1111/bjc.12324 Peters, W., Rice, S., Cohen, J., Murray, L., Schley, C., Alvarez-Jimenez, M., & Bendall, S. (2021). Trauma-focused cognitive–behavioral therapy (TF-CBT) for interpersonal trauma in transitional-aged youth. Psychological Trauma: Theory, Research, Practice, and Policy, 13(3), 313. https://psycnet.apa.org/doi/10.1037/tra0001016 Vogel, E. N., Singh, S., & Accurso, E. C. (2021). A systematic review of cognitive behavior therapy and dialectical behavior therapy for adolescent eating disorders. Journal of Eating Disorders, 9, 1-38. https://doi.org/10.1186/s40337-021-00461-1.