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Evidence-based assessment/Vignettes/Lea

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Lea

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Clinical description

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Lea is an 18 year old white female in regular education in the middle of her senior year of high school. She self-referred to the outpatient clinic because she has been having a lot of trouble with attention and focusing on course material. Her grades are dropping rapidly, and she is getting anxious and worried about graduating (and IF she will graduate). As her anxiety spirals up, her grades are coming down.

(suggested edit to above paragraph) Lea is an 18 year old white female in the middle of her senior year of a regular high school. After experiencing attention problems in her classes and the material, she self-referred to the outpatient clinic. Her rising anxiety is only worsened by the threat against her ability to graduate as her grades continue to spiral out of control.

Extended content

History of presenting problem

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Conceptualization

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Initial treatment plan

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Assessment findings

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Checklist scores

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Lea and her older sister completed the Achenbach System of Empirically Based Assessment (ASEBA) checklists. Here are the results, reported as T scores (M = 50, standard deviation (SD) = 10, compared to other women between 11 and 18 years of age). Note that Lea is estranged from her mother, and has been living with her older sister for more than a year. The clinician had to make a decision whether to have mom fill out the Child Behavior Checklist or CBCL (which would have been a better match to the normative data, but would not have had as much current information) versus having the older sister fill out the form. Lea's sister could provide more recent information, but her perspective might be different from that of other caregivers (usually mothers) making up the normative sample used to estimate the T scores.

ASEBA Scores
Scale Sister Lea
Externalizing 56 61
Internalizing 62 74
Anxious/Depressed 66 70
Withdrawn 54 69
Somatic Complaints 68 72
Attention Problems 70 78
Social Problems 66 75
Thought Problems 64 86
Delinquent/Rule-Breaking 64 68
Aggressive Behavior 51 52
Extended content


Select more specialized scales to fefine probabilities

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Updating probabilities

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Critical items

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Diagnostic interview findings

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Diagnoses are based on a LEAD (Longitudinal expert evaluation of all data)[1] consensus meeting following a Kiddie Schedule for Affective Disorders and Schizophrenia (KSADS) interview, using DSM-IV criteria. The same interviewer met with Lea and then her mother, then discussed any differences of opinion with them as needed to use clinical judgment. KSADS results were reviewed with a licensed clinical psychologist to arrive at a final decision.

  • Bipolar II (major depression + hypomanic episode) (85% confidence post interview)
  • Attention-Deficit/Hyperactivity Disorder (ADHD), Inattentive (85% confidence)
  • Past substance misuse (75% confidence)
  • Current alcohol and marijuana use (70% confidence)
  • Past non-suicidal self-injury (NSSI) (65% confidence)

Cognitive and achievement testing

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(Not done as part of the evaluation; may be able to match up information later)

Prediction phase

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Let's see how we would apply the Evidence Based Assessment (EBA) principles to Lea:

Shortlist of probable hypotheses

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Based on Lea's age and the common clinical issues, here are the possible issues:

  • A mood disorder is a leading hypothesis. The suicide attempt also suggests evaluating mood disorder (although not everyone who attempts suicide has a mood disorder). Within the "mood" category, the hypotheses should consider major depression, dysthymia, and bipolar spectrum disorders, as well as other medical issues that could lead to mood symptoms.
  • Substance misuse should be another hypothesis, based on its prevalence in her age group.
  • Anxiety disorders would be a third hypothesis.
  • Conduct problems would be a fourth -- they are not immediately suggested by the description of the presenting problem, but they are common in the age group, and they also can be a risk factor for self harm.
  • Attention problems are worth evaluating based on prevalence, though her prior academic performance does not suggest any additional reason for concern.
  • The family conflict is also important to assess, as well as potential cultural issues (and differences of opinion between Lea and her parents that might be influenced by differing degrees of acculturation).

Risk and Protective Factors and Moderators

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Lea's gender and age increase the probability of a mood disorder, and may reduce the chances of conduct disorder[citation needed]. Her solid academic performance previously suggests potential resilience.

Her conflict with her father, and her keeping things secret from her parents, would be considerations before doing family therapy, and they may complicate consent for treatment (Lea is still a minor).

Updating probability of diagnoses

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Below is a worksheet with the DLRs left blank to be filled in. Answers are below. 

Lea Common Dx Hypotheses (A) Starting Prob. (B) Broad Measure (D) Cross-informant (E) Confirmation (G) Treatment Phase (I), (J), (K)
Base Rate from Kessler et al. (2005) NCS-R[2] Scale & Score DLR Revised Prob. EAY Check Next Test score DLR Revised Prob. MINI
Any Anxiety Any Anxiety 0.29 YSR T

Internalizing 73

2.35 0.49 0.49 CBCL T

Internalizing 63

0.98 0.48
Specific Phobia 0.13
PTSD 0.06
GAD 0.04
Panic Disorder 0.04
Social Phobia 0.14
Separation Anxiety 0.02
Any Impulse Control Disorder ODD 0.10
CD 0.11
ADHD 0.08 YSR T

Attention 78

1.36 0.11 0.11 CBCL T

Attention 70

2.19 0.21 ADHD Predominanatly Inattentive Type
Any Mood Disorder MDD 0.15 YSR T

Internalizing 73

2.43 0.30 0.30 CBCL Raw

Internalizing 14

0.90 0.28 Major Depressive Episode
BP 0.32 YSR T

Externalizing 61

1.15 0.35 0.35 CBCL T

Externalizing 56

0.53 0.22 Hypomanic Episode --> Bipolar II
Dysthymia 0.02
Any Substance Abuse Disorder 0.17 CBCL #2: 0

CBCL #99: 2 CBCL #105: 1.5

3.40 0.41 0.41 CBCL #2: 0

CBCL #99: 1 CBCL #105: 1

5.60 0.80 Substance Abuse - past cannabis and XanaxTM abuse

Cross-informant perspectives

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Mention that these have DLRs. Also unpack the implications of agreement and disagreement for the client (and add a section about treatment implications of disagreement on the Conceptual Model Pages)

Prescription phase

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Mental status and clinical observations

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Genogram and family functioning

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Here is a genogram of Lea's family. All of the information comes from Lea.

 

Treatment selection

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The diagnostic interview suggests a combination of a major depressive episode and a prior dysthymia, sometimes referred to as a "double depression." This suggests that Lea's stress and mood problems have persisted for a long time, and may be more difficult to treat. The mood disorders clearly are associated with impairment and should be a major focus of treatment.

Interpersonal Psychotherapy

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Interpersonal Psychotherapy (IPT) is a time-limited treatment that focuses on the relationships between the patient and other people. IPT focuses on relationships because they are critical for the well-being and psychological adjustment of the patient. The original purpose of IPT was to reduce symptoms of Depression. However, it is now utilized to improve/enhance the quality of the patient's relationships with others. Research since its development demonstrates that IPT is effective when adapted for mood, eating, and anxiety disorders[3].

IPT has three defined phases (beginning, middle, end) that require strategies and tasks for both the therapist and patient[4]. These phases aim at resolving four main social areas: grief, interpersonal role disputes, role transitions, and interpersonal deficits. The first phase typically lasts 1-3 sessions. During this part of treatment, the therapist conducts a diagnostic assessment and reviews the patient's psychiatric history, which establishes the context for the treatment. The middle phase of treatment focuses on specific strategies to deal with potential problem areas: complicated bereavement, role disputes, role transitions, interpersonal deficits[5]. A role transition is when a person goes from one role in a relationship to another role (e.g., the end of a relationship with divorce or the beginning of a new relationship with marriage). When the end of treatment is near, the clinician/therapist reminds the patient that this is a role transition.

Outcomes of treatment through IPT are influenced by the relations between the patient and significant others. Since there is a time limit on treatment, the patient is pressured to take action as an overall task[5].

Why is IPT a good treatment option for Lea?

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Interpersonal Psychotherapy is a good treatment option for Lea because of its focus on building/maintaining relationships. Lea’s current family conflicts include living with her sister because of her fractured relationships with her mother and father. After receiving her diagnosis of bipolar disorder, she was in denial. This stems from her broken relationship with her father, who was diagnosed with bipolar disorder. IPT can be adapted to focus less on the diagnosis and more on the importance of having healthy relationships.[6]

Moderating factors

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The double depression is a moderating factor suggesting worse prognosis, along with potential demoralization and early drop out from treatment.


Client preferences

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Lea was originally leaning towards an antidepressant medication, thinking that she could take it without telling her parents. After discussing the pros and cons of medication (including the effect size in youths, the potential side effects, and the fact that her parents would find out as part of the consent process), as well as the pros and cons of different evidence based therapies, she elected to try Interpersonal Psychotherapy (IPT). She wanted to revisit the possibility of a stimulant helping with her inattention, but she opted to wait and see if that improved along with her mood if the IPT helped.

Process phase

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Clinically significant change

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Reliable change index

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Pick a treatment target and specify what the RCI would be for it. Discuss how you would explain to Lea

Looking at Lea's self-report internalizing score on the CBCL, she scores 1.04 SD's away from the clinical mean of people her age. In order to say that she is making clinically significant change with 95% confidence we want to see a score reduction of 8.4 post-treatment. To say that she is making clinically significant change with 90% confidence we want to see a score reduction of 7.1 points.

Looking at Lea's self-report attentional problems on the CBCL, she scores1.5 SD's above the mean of people her age with clinical significance. In order to say that she is making clinically significant change with 95% confidence we want to see a score reduction of 8.3 post-treatment. To say that she is making clinically significant change with 90% confidence we want to see a score reduction of 7.0 points.

When reporting this to Lea, a clinician should take her desire for improvement into account. Asking Lea for her desired decrease in scores could be insightful for a clinician when working with Lea. The goal in treatment outcome is for an RCI of 1.96, but client perception of incremental growth when it comes to health is also important. Therefore, the benchmarks of clinically significant change could be framed as client "goals" for self-improvement.

Nomothetic benchmarks

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A, B, Cs of Jacobson definitions. General stuff about limitations would go on the main concept page. Here it is focused on the client -- what are the benchmarks they will focus on? How explained to them?

The benchmarks for Lea's treatment with a treatment focus of internalizing behaviors are as follows:

A = 39.0

B = 70.1

C = 55.6

Interpreting benchmarks

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In order for Lea to move "away" (A) from the clinical population on her internalizing scores, she needs to meet the benchmark A = 39.0. This can be a daunting task and should not be considered the primary goal of treatment.

In order to get Lea "back" (B) into the normal distribution of nonclinical samples for internalizing scores, she needs to meet the benchmark B= 70.1. This is an easy benchmark to meet; however, it is not within the realm of clinically significant change (RCI = 1.96). Therefore, a clinician cannot be 95% certain that the treatment is working unless she is able to reduce her score from 78 to a 65.6.

In order for Lea to be "closer" (C) to the nonclinical mean than the clinical mean of women her age, she needs to meet the benchmark of C=55.6. This benchmark is potentially the most useful for the clinician, although not necessarily for Lea.

Minimum important difference (MID)

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Note that this section is a dangler -- not originally called out in the 12 steps. Medium d as a rule of thumb from Streiner, Norman, & Cairney (2015). Could work from AUC to d to raw units as a way of estimating, since psychology hasn't done research on this yet. Might be able to back into it with studies that had CSQ and outcome data.

Client goals & tracking

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These would be personal goals and idiographic measurement -- YTOPS, etc.

Process measures

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This would be traces such as coming to sessions, doing homework assignments. (Not sure of other specifics involved in current IPT protocols?)

Progress measures

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YTOPS again and goal setting.

Termination planning and maintenance

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Revisit Jacobson benchmarks. Is there much chance of relapse? What things would the client need to pay attention to if they were going to nip that in the bud?

References

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  1. ↑ Spitzer, Robert L. (1983-09). "Psychiatric diagnosis: Are clinicians still necessary?". Comprehensive Psychiatry 24 (5): 399–411. doi:10.1016/0010-440x(83)90032-9. ISSN 0010-440X. http://dx.doi.org/10.1016/0010-440x(83)90032-9. 
  2. ↑ 2.0 2.1 Kessler, Ronald C.; Berglund, Patricia; Demler, Olga; Jin, Robert; Merikangas, Kathleen R.; Walters, Ellen E. (2005-06-01). "Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication". Archives of General Psychiatry 62 (6): 593–602. doi:10.1001/archpsyc.62.6.593. ISSN 0003-990X. PMID 15939837. https://www.ncbi.nlm.nih.gov/pubmed/15939837. 
  3. ↑ Wilfley, Denise E.; Shore, Allison L. (2015). Interpersonal Psychotherapy (in en). Elsevier. pp. 631–636. doi:10.1016/b978-0-08-097086-8.21065-9. ISBN 978-0-08-097087-5. https://linkinghub.elsevier.com/retrieve/pii/B9780080970868210659. 
  4. ↑ "International Society of Interpersonal Psychotherapy - ISIPT". Retrieved 2022-03-01.
  5. ↑ 5.0 5.1 Weissman, Myrna M.; Markowitz, John C.; Klerman, Gerald L. (2017-08). Grief. Oxford University Press. pp. 43–54. http://dx.doi.org/10.1093/med-psych/9780190662592.003.0005. 
  6. ↑ Markowitz, John C.; Patel, Sapana R.; Balan, Ivan C.; Bell, Michelle A.; Blanco, Carlos; Heart, Maria Yellow Horse Brave; Sosa, Stephanie Buttacavoli; Lewis-Fernández, Roberto (2009-02-15). "Toward an Adaptation of Interpersonal Psychotherapy for Hispanic Patients With DSM-IV Major Depressive Disorder". The Journal of Clinical Psychiatry 70 (2): 214–222. doi:10.4088/JCP.08m04100. ISSN 0160-6689. PMID 19192460. PMC PMC8321621. https://www.psychiatrist.com/JCP/article/Pages/toward-adaptation-interpersonal-psychotherapy-hispanic.aspx. 
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