Lea

Clinical description

Lea is an 18 year old White female in regular education. She self-referred to the 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.

Extended content
History of presenting problem Conceptualization Initial treatment plan

Assessment findings

Checklist scores

Lea's older sister and Lea both 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 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Withdrawn	54	69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

Updating probabilities

Critical items

Diagnostic interview findings

Diagnoses are based on a LEAD (Longitudinal expert evaluation of all data) 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

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

Prediction phase

Let's see how we would apply the EBA principles to Lea:

Shortlist of probable hypotheses

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

A mood disorder definitely 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 again 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

Lea's gender and age increase the probability of a mood disorder, and may reduce the chances of conduct disorder. 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).

Some data suggest that Interpersonal Psychotherapy (IPT) may be particularly effective with Hispanic teens, perhaps moreso than Cognitive Behavioral Therapy (CBT), because of the greater emphasis on family (and familism). IPT would have an advantage of not requiring active participation of the father (unlike family therapy), since IPT is designed as an individual therapy.

Updating probability of diagnoses

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)
	Base Rate from Kessler et al. (2005) NCS-R^[1]		Scale & Score	DLR	Revised Prob.	EAY Check	Next Test score	DLR	Revised Prob.	MINI
Any Anxiety	Any Anxiety	0.29	YSR T Internalizing 73				CBCL T Internalizing 63
	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				CBCL T Attention 70			ADHD Predominanatly Inattentive Type
Any Mood Disorder	MDD	0.15	YSR T Internalizing 73				CBCL Raw Internalizing 14			Major Depressive Episode
	BP	0.32	YSR T Externalizing 61				CBCL T Externalizing 56			Hypomanic Episode --> Bipolar II
	BP	0.32	YSR T Externalizing 61				CBCL T Externalizing 56			Hypomanic Episode --> Bipolar II
	Dysthymia	0.02
Any Substance Abuse Disorder		0.17	CBCL #2: 0 CBCL #99: 2 CBCL #105: 1.5				CBCL #2: 0 CBCL #99: 1 CBCL #105: 1			Substanc Abuse - past cannabis and XanaxTM abuse

Answers

Lea	Common Dx Hypotheses (A)	Starting Prob. (B)	Broad Measure (D)				Cross-informant (E)			Confirmation (G)
	Base Rate from Kessler et al. (2005) NCS-R^[1]		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
	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	Substanc Abuse - past cannabis and XanaxTM abuse

Cross-informant perspectives

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

Mental status and clinical observations

Genogram and family functioning

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

Treatment selection

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.

Moderating factors

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

Client preferences

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 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

Clinically significant change

Reliable change index

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

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

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)

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

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

References

1 2 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.

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[:0-1] 1 2 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.

Lea