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Tuesday, August 17, 2010

Sample Case Vignette: Harrison Interventions


Harrison, a high school student, is referred by a medical doctor.  The doctor suggests that an unhealthy family dynamic may have resulted in Harrison developing an ulcer and then not following medical treatment even though it would likely relieve his ulcer symptoms.  Harrison's parents say that he seems unhappy and that athletics has taken over his life.  Harrison angrily says he is the victim and the problem is his parents constant worry about him.  He insists that his mother is controlling and that his father goes along when his mother is "getting crazy."  His father describes pride in Harrison's athletic prowess and commitment to wrestling but is concerned that Harrison eats excessively after dieting for days in an attempt to make his wrestling weight.  After sessions of eating, Harrison engages in strenuous exercise and takes pills he purchases at a health food store to manage his weight.  Harrison insists that he follows the label instructions on the diet supplements.  Harrison is not underweight and family members deny any evidence of throwing up to keep his weight down.  Recently Harrison has been skipping school to work out which has affected his grades.  

What interventions are appropriate for the vignette above?


A

Get a consent to discuss Harrison's training program with his wrestling coach.
Introduce a behavior modification program designed to get Harrison going to school regularly.
Refer Harrison back to the medical doctor for treatment of his ulcer.
Refer Harrison to a child psychiatrist for a medication evaluation.

B

Work with the parents to develop consistant rules and rewards to reinforce healthy behaviors in Harrison and get him back in school.
Have the parents monitor Harrison for one half hour after meals to eliminate the possibility he is throwing up in an effort to reduce his weight. .
Refer Harrison for a second medical opinion examining the impact of his binging, exercise and the ulcer.
Refer Harrison to a neuropsychologist to eliminate the possiblity that his binging is not the result of a neurological condition.

C

Consider hospitalizing Harrison as a danger to himself until his exercise and binging is under control.
Get an Authorization to speak with Harrison's doctor.
Begin individual therapy with Harrison.
Consider a DBT group focused on eating disorders.

D

Suggest that Harrison attend a meeting of Narcotics Anonymous to address his over use of pills.
Initiate structural family therapy session and meet with the family each week.
Refer Harrison's mother to individual counseling.
Refer both parents to parent support and education groups to help them better cope with Harrison's behaviors.

1 comment:

  1. A 0+2+2+3=7

    1. Get a consent to discuss Harrison's training program with his wrestling coach.

    (0) Harrison may have a severe eating disorder and his wrestling coach should not be contributing to a plan to manage his eating and compensatory behaviors.

    2. Introduce a behavior modification program designed to get Harrison going to school regularly.

    (2) While school attendance is not the paramount problem in the vignette, this will ad structure to Harrison's life and replace maladaptive behaviors (working out too much) with adaptive ones.

    3. Refer Harrison back to the medical doctor for treatment of his ulcer.

    (2) This is tough to score. Harrison is refusing treatment with the current medical doctor; but you have give significant weight to medical interventions given the risk.

    4. Refer Harrison to a child psychiatrist for a medication evaluation.

    (3) Harrison is very likely suffering from Bulimia Nervosa Non-Purging type. There are medications that help reduce associated symptoms including agitation, depression and anxiety.

    B 2+3+3+2=10

    1. Work with the parents to develop consistent rules and rewards to reinforce healthy behaviors in Harrison and get him back in school.

    (2) While school attendance is not the biggest problem, school will add structure to Harrison's life and replace maladaptive behaviors with adaptive ones.

    2. Have the parents monitor Harrison for a half hour after meals to eliminate the possibility he is throwing up.

    (3) Harrison may be purging and not telling anyone (including you). It would help both you and his parents to understand the extent of the problem.

    2. Refer Harrison for a second medical opinion examining the impact of his binging, exercise and the ulcer.

    (3) Medical interventions have to appear in the correct answer as long as Harrison is refusing the medical treatment that he needs.

    4. Refer Harrison to a neuropsychologist to eliminate the possibility that his binging is not the result of a neurological condition.

    (2) Maybe. There are some rare neurological conditions that cause of the binging.

    C 1+2+2+2=7

    1. Consider hospitalizing Harrison as a danger to himself until his symptoms are under control.

    (1)You are unsure of the extent of the problem, hospitalization is premature.

    2. Get an Authorization to speak with Harrison's doctor.

    (2) You will want to understand the doctor's perspective including why Harrison is resisting treatment and his thoughts about the "family dynamic."

    3. Begin individual therapy with Harrison.

    (2) It is important to develop a therapeutic rapport with Harrison as he is not participating in treatment.

    4. Consider a DBT group focused on eating disorders.

    (2) Harrison appears to have an eating disorder and he is defensive and self-sabotaging (skipping school to work out). Consider DBT when you see eating disorders and self destructive behaviors.

    D 1+2+0+2=5

    1. Suggest that Harrison attend a meeting of Narcotics Anonymous to address his use of pills.

    (1) We don't know if Harrison is misusing pills. We have to know more before suggesting NA.

    2. Initiate structural family therapy session and meet with the family each week.

    (2) Family therapy is often very helpful where a teen presents with symptoms of an eating disorder.

    3. Refer Harrison's mother to individual counseling.

    (0) There is no indication she needs therapy.

    4. Refer both parents to parent support and education groups to help them better cope with Harrison's behaviors.

    (2) Family support and education groups can help parents gain a sense of control over what to do as well as normalizing their experiences.

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