Evidence Based Psychotherapy

Fall 2008

Final Exam Question

 

 

Assume the following patient has come to see you:

 

            Rachel is a 22 year old woman of Cuban descent; she is six feet tall and weighs 150 pounds. Rachel is slender in appearance, with long black hair and brown eyes. She is well dressed, and pays meticulous attention to every aspect of her physical appearance. Most would say that Rachel is a striking individual, but she does not share that sentiment. Her body disgusts her; in particular, she feels that her stomach is flabby, her face is too round, her arms are undefined, and her legs are disproportionate to the rest of her body. She avoids mirrors at all costs, and she has not been shopping in a year because she is not willing to think about her size and is not willing to confront the idea that her size has become larger.

 

Over the past year, Rachel has put forth every effort to lose weight. In the beginning of her weight loss attempt she kept a very strict eating regimen. She was able to maintain this eating regimen of about 750 calories per day until a little over 6 months ago when she had a "slip." After a particularly stressful day at work, she came home to her apartment and scanned the kitchen for junk foods. She grabbed a jar of peanut butter and began to cry. After she ate ½ the jar of peanut butter her appetite raged on. She found a cheesecake belonging to her roommate in the refrigerator and she ate the entire cake. Afterward, she felt uncomfortably full, continued to cry, and then began to panic because she had consumed more calories in 20 minutes than she had the entire week. Eager to regain her control over the situation, she ran to the bathroom, forced her finger down her throat and vomited until she felt that her stomach was empty.

 

Over the next few months her mood and stress level continued to worsen, as did her urge to eat. For the past three months, Rachel has been bingeing on junk foods nearly four times per week. After each binge, she tries to get rid of the calories by vomiting and by using laxatives and diuretics.

 

Rachel is extremely frustrated with her failed weight loss attempts and frequent loss of control over her food intake. She frequently fights with her roommate over missing food, has a difficult time sleeping, and feels tired much of the time. Other than her weight, she has never had any health concerns. Recently, Rachel's older sister Monica has begun to express concern about Rachel's mood and behavior and has urged her to seek treatment. Monica arranged for Rachel's appointment with you after receiving a referral from a co-worker who saw you last year for couple's therapy. 

 

 

 

 

 

 

 

 

 

 

 


Answer the following questions based on this case. (You may make assumptions regarding missing information to answer these questions, but you should describe these in your answer). Specifically be sure to (a) make explicit all assumptions and (b) provide a detailed rationale for your decision making process so I can assess how you approached and came to the decisions you did in this case. A response (e.g., suggested intervention) without an explanation of why you came to that decision (e.g., what you considered and why) will result in lost points.

 

 

  1. What additional historical, clinical and assessment information (formal and informal) would you want and why?

 

  1. Given the evidence provided, provide a thorough diagnostic conceptualization including:
    1. Use DSM-IV-TR to complete a multi-axial diagnosis
    2. Include any rule outs you would consider
    3. Provide a rationale for your diagnosis, detailing the criteria used
    4. What referrals would you consider and why.

 

  1. Based on your case conceptualization, hypothesized functional analysis, and understanding of the relevant literature, discuss what services woul you provide and why.

 

  1. Discuss how you would evaluate the success of your clinical intervention with this individual.

 

  1. Using the APA code of ethics as your guide, list the ethical issues that this case presents. Discuss the additional information and steps that you would need to take (if any) to make sure that you are not in volation of the ethical code of conduct while interacting with this client.

 

 

 


 

 

Scoring key

 

20-point Scoring Scale for Each Question (100 points total)
18-20 = Exceeds expectations/Pass
16-17 = Meets expectations/Pass
14-15 = Several Deficiencies/Fail
0-13 = Many Deficiencies/Fail

 

1.     What additional historical, clinical and assessment information (formal and informal) would you want and why?

1.     Response should indicate awareness that a comprehensive multidimensional (biopsychosocial) assessment is required including:

                                                        i.     Eating dx signs and symptoms, e.g.,

1.     longitudinal history regarding actual and desired BMI;

2.     current eating patterns (e.g., food restriction/avoidances; frequency and extent of binges; self-induced vomiting, spontaneous vomiting; use of laxatives, diuretics, diet pills, ipecac)

3.     reasons for desiring weight loss;

4.     menstruation onset and patterns;

5.     body-images disturbances;

6.     food attitudes and cognitive distortions;

7.      ritualistic/compulsive eating/exercise behaviors;

8.     client's perceptions of etiological and maintaining factors of significance including role of interpersonal relationships

 

                                                       ii.     Psych status and history, e.g.,

1.     comorbid problems including mood and anxiety disorders, suicidality, substance abuse, obsessive and compulsive symptoms, personality disturbances (including shoplifting, food stealing, self harm)

2.     developmental history (including temperament, victimization, sexual history)

3.     relevant interpersonal issues

4.     anticipated treatment barriers and strengths (e.g., personal, external)

 

                                                      iii.     Physical health status and history

1.     although none reported in the brief vignette, more thoroughly assess possibility of current and past medical problems

2.     current treatments (e.g., meds)

3.     med history

4.     physical exam (may include e.g., dental exam, labs) and/or medical record

 

                                                     iv.     Family/social assessment (current and history)

 

                                                      v.     Assess for other psychosocial and environmental problems relevant to diagnosis, treatment, or prognosis [see list in DSM pages 31-2]

 

 

 

 

2.     Given the evidence provided (and any you create), provide a thorough diagnostic conceptualization including:

    1. Use DSM-IV-TR to complete a multi-axial diagnosis

 

                                               i.         Axis I: bulimia nervosa, binge/purge subtype [see DSM criteria pages 589-595]

1.     rule out other possibly comorbid Axis I disorders (e.g., mood disorder, substance abuse)

 

                                              ii.         Axis II: not clearly assessed in vignette; rule out possibly comorbid personality disorders (e.g., obsessive compulsive personality dx, borderline, etc.)

 

                                             iii.         Axis III: although client reported no previous health concerns in the brief vignette, carefully rule out general medical conditions (including use of medications and other substances) that are potentially relevant to understanding or management

 

                                            iv.         Axis IV: Psychosocial and environmental problems that may affect diagnosis, treatment and prognosis (see DSM p. 31). Depending on assumptions made and info that emerges from assessment (above), any number of these may apply

 

                                             v.         Axis V: Clinician overall assessment of patient level of functioning will depend on assumptions made and info that emerges from thorough assessment. Key to response will be that clinician adequately justifies GAF with evidence from the case and subsequent assessment data.

 

    1. Include any rule outs you would consider

                                               i.         See above

    1. Provide a rationale for your diagnosis, detailing the criteria used

                                               i.         DSM criteria pages 589-595

 

    1. What referrals would you consider and why

                                               i.         Medical assessment (see question 1 above, item iii)

                                              ii.         Consider coordinated care plan that collaborates with other relevant professionals (e.g., for nutritional counseling, medical management/monitoring, etc); specifics will depend on details that emerge from comprehensive assessment

 

                                                                                   

3. Based on your case conceptualization, hypothesized functional analysis and understanding of the relevant literature, discuss what services, if any, you would provide and why.

  1. CBT is considered the gold standard for BN, followed by IPT
    1. referral to nutritionist/psychiatrist on as needed basis
  2. Some more recent evidence that DBT works—but student would need to provide statement that a full DBT team were available to assist in treatment; not accptable to provide DBT-type treatment as the sole clinician.
  3. Accept another type of treatment approach, if student can cite evidence in the published literature of its efficacy

 

 

4. Discuss how you would evaluate the success of your clinical intervention with this individual.

 

  1. Answer need to reflect monitoring of and decrease in symptoms with self-report measures/self-monitoring logs
    1. examples include food records, automatic thought records (if CBT is used), binge/purge logs, eating disorder measures, body image measures—specific measures are not necessary.
  2. Single subject design may be appropriate, as long as interventions are not removed in an unethical manner (those who have taken the evidence-based therapy course might be more likely to include this in their answer).

 

5. Using the APA code of ethics as your guide, list the ethical issues that this case presents. Discuss the additional information and steps that you would need to take (if any) to make sure that you are not in violation of the ethical code of conduct while interacting with this client.

 

 

Must list all of the following concerns:

  1. Competency:(e.g., discussion about therapist needing to have the knowledge and skills necessary to treat this condition(s) or to understand multicultural issues, etc.)
  2. Confidentiality: It may be reasonable to discuss the provider's need to be aware of and appropriately address potential issues regarding the client's confidentiality with regard to her sister's involvement in her care.
  3. Any other ethical issue that is consistent with additional information provided by the student and has a solid rationale.