Help Needed

11 Feeding, Eating and Elimination Disorders

The diagnostic criteria for the Feeding and Eating Disorders in this chapter are categorized by recurrent disordered eating activities and attitudes that are mutually exclusive, with the exception of pica, which results in significant physical and/or psychosocial impairment ( APA, 2013 ). Research demonstrates that eating disorders often originate in childhood or adolescence with the average age of onset between 8 and 21 years ( Hudson, Hiripi, Pope, & Kessler, 2007 ). Approximately 20 million women and 10 million men in the United States suffer from a clinically significant eating disorder during their lifetime ( Wade, Keski-Rahkonen, & Hudson, 2011 ). Despite this prevalence, only one in ten individuals with an eating disorder receives treatment (Noordenbox, 2002). It is estimated that over 90% of those diagnosed with an eating disorder are young females between the ages of 12 and 25 ( SAMHSA, 2003 ), but adult males suffer significantly as well ( EDC, 2007 ).

   Data from the National Comorbidity Replication Survey (NCS-R) and the Adolescent Supplement (NCS-A) show that adults and children with eating disorders often have coexisting mental disorders such as depression, anxiety, and substance use; sadly, few seek treatment specific to their eating disorder. More distressing, this data demonstrates that eating disorders are often associated with functional impairment and suicidality ( Hudson et al., 2007 ;  Swanson, Crow, Le Grange, Swendsen & Merikangas, 2011 ).

   The first three disorders were relocated to this category “Feeding and Eating Disorders” to highlight that although they are most often diagnosed in children, they can occur at any age, including adulthood. These disorders are distinguished by problems with the process of eating and retaining food, eating inappropriate food, or lack of interest in or avoidance of food. Among individuals with intellectual disabilities their presence appears to increase with the severity of the condition. Pica Disorder is the eating of nonfood items such as paint chips, string, hair, or newspaper. Although it may occur with other eating and mental disorders, symptoms must be severe enough to warrant an independent diagnosis. Rumination Disorder involves vomiting and re-eating food. Avoidant/Restrictive Food Intake Disorder was formerly feeding disorder of infancy or early childhood, but it has been expanded to capture a broader range of symptoms and age levels. This disruption in eating and feeding behavior is marked by continuous inability to meet appropriate sustenance and dietary needs. It is associated with a serious decrease in body weight, failure to grow, nutritional deterioration, reliance on enteral feeding and impairment in psychosocial functioning ( APA, 2013 ). For any of these diagnoses, all three eating disorders should not develop solely during the course of another eating disorder and cannot be a culturally sanctioned practice or attributable to a medical condition or another mental disorder (See DSM-5 for full description of these disorders.)

   The following three eating disorders are considered very serious due to their chronic nature and morbidity, especially without treatment. The first, Anorexia Nervosa, has an annual prevalence rate of “0.4% among young females, with a 10:1 female-to-male ratio” ( APA, 2013 , p. 341) and is characterized by significant weight loss resulting from excessive dieting and a distorted body image. “Significantly low weight is defined as a weight that is less than minimally normal or, for children and adolescents, less than minimally expected” ( APA, 2013 , p. 338). Individuals affected by this disorder have an unreasonable fear of becoming fat regardless of their low body weight, which interferes with weight gain. This intense focus on being thin is often accompanied by a distorted body image; that is, the individuals experience their weight or shape as greater than what it actually is and often lack insight into the gravity of their low body composition ( APA, 2013 ).

   There are two subtypes of Anorexia Nervosa: Restricting Type and Binge/ Purging Type. Subtypes are used to identify current symptoms over the last 3 months and often alternate between subtypes. Individuals with the Restricting Type severely restrict their food intake without engaging in bingeing or purging behaviors. Individuals with the Binge/Purging Type of anorexia maintain their weight at an abnormally low level through food restriction but also engage in binge eating and purging behaviors, such as self-induced vomiting or laxative or diuretic abuse. Clinicians need to specify if individuals are in partial (some of the criteria are met) or full (no criteria are met) remission if the client previously met the full criteria. Also, the current severity level of clinical symptoms and functioning needs to be indicated from mild to extreme based on body mass index (BMI) for adults and percentiles for children and adolescents ( APA, 2013 ).

   Another significant eating disorder, Bulimia Nervosa (BN) is also more prevalent in young females, “estimated at 1% to 1.5%” with female-to-male ratios similar to anorexia ( APA, 2013 , p. 347). Individuals suffering from bulimia generally maintain a normal weight for their age and height. The primary issue for the individual diagnosed with bulimia is a pattern of binge eating that occurs at least once per week for 3 months. This is followed by contradictory actions to avoid weight gain, such as vomiting; laxative, diuretic, or enema abuse; fasting; or excessive exercise. Additionally, bulimia is accompanied by both a loss of control and excessive concern related to body shape/weight. A binge consists of eating a larger amount of food than normal under similar circumstances in a relatively short period of time (usually less than 2 hours). To meet diagnostic criteria, the bulimic behavior must not occur entirely during episodes of anorexia nervosa. Clinicians need to specify whether in partial or full remission as well as severity level based on frequency of episodes of inappropriate compensatory behaviors, from mild to extreme ( APA, 2013 ).

   Binge Eating Disorder (BED) became a diagnostic category in the DSM-5 and is defined as repeating episodes of excessive eating accompanied by feeling a loss of restraint and marked distress. To meet diagnostic criteria, 3 out of 5 of the following features must be present: eating more quickly than is typical; eating without the physical sensation of hunger; eating until excruciatingly full; eating alone out of shame over amount consumed; and, feeling hopeless, remorse, and depressed afterward. For diagnosis, frequency of bingeing episodes must be at least once per week for 3 months and cannot arise only during the course of anorexia or bulimia. Diagnosis must specify the current severity of binge episodes (from mild to extreme) as well as remission status (partial/full) if applicable ( APA, 2013 ).

   Although BED is the most common eating disorder there is limited knowledge about its development. Annual prevalence “among U.S. adult (age 18 or older) females and males is 1.6% and .08%, respectively” ( APA, 2013  p. 351) to lifetime prevalence rates of 3.5% in women and 2.0% in men ( Hudson et al., 2007 ). Gender differences are closest in BED than in either anorexia or bulimia, with development still more prevalent in women. However, for subthreshold BED, this gender ratio reverses with males 3 times higher than females ( Hudson et al., 2007 ). BED has been shown to occur across the developmental lifespan with age of onset generally reported as adolescence but occurrence in adulthood is not uncommon ( APA, 2013 ).

   Eating Disorders Not Otherwise Specified (EDNOS) has been replaced with two categories. The first, Other Specified Feeding or Eating Disorder, applies to demonstrations that do not meet the full criteria for any of the eating disorders in this section. It is used when the “clinician chooses to communicate the specific reason that the presentation does not meet the criteria for any specific feeding and eating disorder” ( APA, 2013 , p. 353), which must be included in diagnosis (for examples see DSM-5). The other category, Unspecified Feeding or Eating Disorder, is used to signal that there is inadequate information available for the clinician to make a more specific diagnosis, such as in an emergency room setting ( APA, 2013 ).

Assessment

In assessing a client with a potential eating disorder, it is important to conduct a thorough psychosocial evaluation, including demographic information, reason for visit (which may be different from the principal diagnosis), support systems, family information, medical history, and any other history of mental health intervention (see  Chapter 1 ).

   Clients who present with eating-disordered symptomatology may not initially feel comfortable discussing behaviors associated with the disorder due to the stigma, shame, and fear of being discovered. Often, the behaviors have been held secret for a significant period of time. The clients may be afraid of family and friends pressuring them to change the behavior before they are ready to make any changes.

   Even when the eating-disordered person appears confident, accomplished, fearless, and intelligent, the internal experience is painful (e.g., terror of “getting caught,” pervasive feelings of confusion or turmoil, concern about “going crazy”). Although it may be obvious that the client has an eating disorder, several sessions may be required before the client is willing to acknowledge the problem. Family members may even maintain or support such denial because eating-disordered behaviors (e.g., dieting, overeating, abstaining from eating, overexercising) are learned from the previous generation.

   Although a client may be able to talk about the eating disorder, the client or his or her family may question the validity of such a diagnosis. For example, the parents of an anorectic girl might suggest that their daughter just wants to look like all the models in the magazines. In order for the practitioner to address this defensive stance, it is crucial to join with the family and establish good rapport and communication; a nonjudgmental and empathic attitude; and a calm, neutral, matter-of-fact tone concerning the eating-disordered symptoms. If the clinician infuses the assessment interview with too much emotion, the client and family may intensify their guardedness and withdraw from treatment.

   Adolescents with eating disorders are often pressured into therapy by their parents, school counselors, friends, or relatives. Their resistance to therapy may require the practitioner to focus on other nonfood- or weight-related issues for a considerable length of time before the adolescents develop enough trust to confide in the therapist. Adults with eating disorders may be motivated to come into therapy for a variety of reasons other than wanting to recover from the eating disorder. Such reasons may include wanting to assuage the family's or friends' worries; fear of a particular medical manifestation, such as bleeding, tachycardia, or incontinence; or problems with interpersonal relationships.

   Assessment of an individual who the practitioner suspects might have an eating disorder involves exploring several specific areas that pertain to eating behaviors and attitudes. First, the practitioner should obtain a history of dieting or compulsive eating habits. Second, the client should be assessed for present symptoms of specific eating-disordered patterns (e.g., restricting food intake, vomiting, abusing laxatives, hiding food, hoarding food, having strict lists of “safe” foods, being obsessed with recipes and cooking, and engaging in excessive exercise routines).

   Often these behaviors are accompanied by symptoms of depression, low self-esteem, distorted body image, hopelessness, anxiety, and, in more severe cases, suicidal tendencies. Due to the possibility of comorbidity, specific assessments can be conducted to rule out concurrent mental disorders such as substance abuse, major depression, body dysmorphic disorder, and obsessive-compulsive disorder. In addition, personality disorders such as borderline personality disorder, dependent personality disorder, histrionic personality disorder, and avoidant personality disorder should be considered.

   People with eating disorders tend to have very rigid, fixed thought patterns. This may affect their social relationships, interpersonal skills, and ability to maintain intimate connections with other people (e.g., close friends, partners, close work relationships, family ties). If the client is under 18 years old, the family situation should be thoroughly assessed. Family factors that have been found to contribute to anorectic behavior in adolescence include enmeshed family systems, blurred boundaries between parents and children, and lack of separation and individuation. Family factors that may influence bulimic and compulsive overeating behaviors include chaotic family dynamics, power imbalances, lack of flexibility, and a lack of clear family structure. In all types of eating disorders, factors that characterize families could potentially include a history of sexual abuse or traumatic events, squelching of emotional expression, and power and control issues.

   Finally, it is essential that the eating-disordered client's case be followed by a medical doctor while the client is in therapy for the eating disorder. Clients with anorexia who fall below a minimum weight are often hospitalized because of the life-threatening risks that emaciation poses. Bulimic clients can develop electrolyte imbalances and other physical problems that can lead to medical complications. It is often necessary to have a written contract with eating-disordered clients stating that if they fall below a certain minimum weight, they understand that they will be hospitalized. In addition, the practitioner must obtain written consent from clients to exchange information with the physician.

Assessment Instruments

The Eating Disorder Examination (EDE;  Cooper & Fairburn, 1987 ;  Fairburn & Cooper, 1993 ) is a well-validated and widely used instrument to diagnose eating disorders ( Cooper, Cooper, & Fairburn, 1989 ; Grilo et al., 2010;  Rizvi, Peterson, Crow, & Agras, 2000 .  Peterson, Crow, & Agras, 2000 ). This semistructured interview in its 16th edition, takes approximately 1 hour to administer and assesses anorexia nervosa, bulimia nervosa and binge eating disorder based on responses to 33 open-ended questions (both Likert and dichotomous). Training in both the technique of the interview as well as the instrument is required.

   The EDE is composed of 4 subscales related to the cognitive symptomatology of eating disorders that measure dietary restraint as well as eating, weight, and shape concern. Also, behavioral symptoms are assessed including frequency of binge eating, self-induced vomiting, laxative/diuretic misuse, and excessive exercise. Scoring for these subscales is on a 7-point scale (0–6) with higher scores indicating greater frequency or severity of symptoms. For most items a 28-day timeframe is employed, except for diagnostic purposes when a longer time period may be required. A symptom composite score can be calculated by averaging the diagnostic items. Research indicates good internal consistency ( Cooper et al., 1989 ) and inter-rater reliability and test–retest reliability (Reas, Grilo & Masheb, 2004) over 2 to 7days for all the EDE subscales and high inter-rater reliability ( Rizvi et al., 2000 ). Good inter-rater reliability and test–retest reliability for the EDE (6 to 14 days) was shown in adult patients with BED (Reas et al., 2004). Research by Berg, Peterson, Frazier, and Crow ( 2012 ) demonstrates that the EDE scores correlate with measures of similar constructs and support the use of this instrument to distinguish between eating disorder cases and controls; however, they point out that no studies to date have assessed the inter-rater reliability of scores on items that assess laxative/diuretic misuse or excessive exercise. There is a child's version (ChEDE) of this scale designed specifically for use with children ages 8 to 14 ( Bryant-Waugh, Cooper, Taylor, & Lask, 1996 ) as well as a self-report questionnaire (EDE-Q) that have been shown to correlate with the EDE.

   The Eating Disorder Inventory-3 (EDI-3;  Garner, 2004 ) is a self-report questionnaire used to assess the symptoms and presence of eating disorders in individuals aged 13 and above. This is the third version of one of the most popular self-report scales (EDI;  Garner, Olmsted, & Polivy, 1983  & EDI-2,  Garner, 1991 ), and it consists of 91 items (same as EDI-2) that are rated on a 6-point scale from “always” to “never.” It is organized into 12 scales (e.g., drive for thinness, bulimia, body dissatisfaction) and yields 6 composite scores, including eating disorder risk and 5 common psychological constructs. Higher scores indicate a greater likelihood of an eating disorder. Furthermore, this version included individuals with an EDNOS diagnosis, which covers binge eating. The EDI-3 demonstrates good discriminative validity and good to adequate internal consistency ( Garner, 2004 ; Cumella, 2006) with recent studies of women demonstrating results that were even better than the original ( Clausen, Rosenvinge, Friborg, & Rokkedal, 2011 ).

   The Eating Disorder Diagnostic Scale (EDDS; Stice, Telch, & Rizvi, 2000) is a brief, 22-item, self-report screening measure of anorexia nervosa (AN), bulimia nervosa (BN), and binge eating (BE) disorders. The items can be standardized for consistency and averaged (with the exception of 2 items) to provide a symptom composite score, and the scale can be administered in less than 10 minutes. Psychometric studies provided criterion, convergent, and predictive validity of the EDDS with samples containing adolescents and adults, as well as nonclinical and clinical populations. The eating disorder symptom composite demonstrated internal consistency (.89) and convergent validity with similar scales assessing eating pathology (EDE and SCID-I). The 1-week test–retest coefficients were .95 (AN), .71 (BN), and .75 (BED) (Stice et al., 2000; Stice, Fisher, & Martinez, 2004). Krabbenborg et al. ( 2011 ); established an overall symptom composite cutoff score of 16.5, which accurately distinguished those with a disorder from controls and may be useful in identifying subthreshold patients as well as detecting possible protective intervention effects. Later factor analysis found good internal consistency related to four factors of the scale: body dissatisfaction, bingeing behaviors, bingeing frequency, and compensatory behaviors ( Lee et al., 2007 ).

   The Eating Attitudes Test (EAT-26;  Garner, Olmsted, Bohr, & Garfinkel, 1982 ) is a brief, self-report screening measure of eating disorder symptoms and is not intended to make a diagnosis. Many studies have been conducted using the EAT-26 as a screening tool, including the 1998 National Eating Disorder Screening Program (NEDSP). This 26-item questionnaire contains 3 subscales: dieting (13 items), bulimia and food preoccupations (6 items), and oral control (7 items). Respondents must rate whether each item applies on a 6-point scale (e.g., “always,” “usually,” “often,” “sometimes,” “rarely,” or “never”). Items are summed to produce a total score. Clients who score above 20 are considered at risk for an eating disorder and referred for a diagnostic interview. Additionally, information is gathered on the individual's BMI, and five behavioral questions ask about weight-control behaviors (e.g., binge, vomit, laxative/diuretic, exercise, and weight loss). The EAT-26 is easy to administer and score and has good psychometrics (Mintz & O'Halloran, 2000).

   The EAT-26 does not yield a specific diagnosis of an eating disorder. A disorder must have a prevalence approaching 20% in order for the test to be efficient in detection. This instrument was developed and validated on primarily female populations and is most often used to assess female high school and college students. The EAT-26 can be useful in measuring pathology in underweight girls but also shows a high false-positive rate in distinguishing eating disorders from disturbed eating behaviors in college women.

   The EAT-26 has a children's version (ChEAT-26;  Maloney, McGuire, & Daniels, 1988 ) for use with children aged 8–13 years with psychometric properties similar to the adult version (alpha = .88 with low item 19 deleted) and a suggestion that this measure be further modified if used with younger children since alphas increased with each grade level. The standard cutoff score of 20, which is used with adults, was recommended (Smolak & Levine, 1994;  Sancho, Asorey, Arija, & Canals, 2005 ). Lack of honesty or accuracy in self-reporting can limit the usefulness of the EAT-26, particularly with anorexia. However, the EAT-26 has been shown to be useful in detecting cases of anorexia nervosa, and the assessor can then combine information gained from this assessment and other assessment procedures to make a diagnosis ( Maloney et al., 1988 ).

Emergency Considerations

Eating disorders are among the most lethal psychiatric illnesses in the DSM-5 ( APA, 2013 ). Meta-analysis conducted by Arcelus, Mitchell, Wales, and Nielsen ( 2011 ), found that mortality rates are substantial among individuals with eating disorders, especially in those with anorexia nervosa. The weighted annual mortality rates were 5 per 1000 person-years for anorexia nervosa (AN), 1.7 per 1000 person-years for bulimia nervosa (BN), and 3 per 1000 person-years for EDNOS. More striking, one in 5 individuals with AN who died had committed suicide. Additionally, age at assessment was found to be a significant predictor of mortality for individuals with anorexia. Utilizing data from the National Comorbidity Survey Replication Adolescent Supplement, Swanson et al. ( 2011 ) found that most adolescents who had a diagnosis of AN, BN, and BED in the past 12 months reported significant role impairment (97%, 78%, and 63%, respectively) especially in their social and family relationships. Moreover, suicide risk was demonstrated for all eating disorders. Bulimia and subclinical anorexia were correlated with suicide plans, and BN and BED were linked with suicide attempts.

   Due to the physical complications that can develop from starvation, laxative abuse, diuretic abuse, and vomiting behaviors, clients with eating disorders can develop life-threatening medical conditions that require emergency medical procedures. Therefore, the practitioner who is working with eating-disordered clients must develop a “team” approach to treatment and include a physician or nurse practitioner, a dentist, a nutritionist, and other medical professionals on the treatment team to effectively treat the client.

   Clients with eating disorders also often suffer from severe depressive episodes that may lead to feelings of hopelessness and, ultimately, suicidal behaviors. If the practitioner assesses the client to have depressive symptoms, the severity of the depression along with suicidal ideation should be considered. Crisis intervention strategies should be utilized and a psychiatric evaluation conducted if necessary to stabilize the client and keep him or her safe.

Cultural Considerations

Culture beliefs and attitudes are factors that influence the development of eating disorders ( Miller & Pumariega, 2001 ). It is important to recognize that in the developed Western European and North American countries, food is taken for granted, and only in countries in which there is an abundance of food do eating disorders flourish. Poor and underdeveloped countries in which food is scarce have far fewer eating-disordered individuals among their populations. Cultural values, therefore, are an important aspect of this illness. Culture shapes both attitudes and behaviors related to body image and eating, especially when values about physical aesthetics are involved. For example, some cultural risk factors for anorexia include social pressure to be thin (e.g., media attention/peer pressure) and the focus on body image (Polivy & Herman, 2002; Striegel-Moore & Bulik, 2007). Western culture's emphasis on thin idealization can contribute to eating disorders, but it is not solely culpable. Although the underlying causes of eating disorders are not entirely clear, a multifactorial relationship that includes biological, psychological, and sociocultural factors is most accepted.

   There is a growing controversy over why the number of minorities with eating disorders is relatively low. Many feel that the research on eating disorders in women of color suffers from both underreporting and researcher bias ( NEDA, 2012 ), both of which can result in minorities going undiagnosed. Some studies show that the experiences of African-American and Caucasian female adolescents are extremely different, with African-American girls being proud of their bodies regardless of the cultural pressure to be thin ( Woodrow Wilson International Center for Scholars, 2000 ). A cultural identity that embraces larger body types than does the dominant culture may account for why some African-American women are at a lower risk than White American females for developing eating disorders that focus on thinness. This suggests that a protective effect may exist in terms of ethnicity and culture for black American females against the development of some eating related psychopathology. However, Asian women reported equal to higher levels of eating dysfunction as white American women (Wildes, Emery, & Simons, 2001). In contrast, research on Latinas showed that they are more inclined to exhibit binge eating rather than restricting behaviors (Smolak & Striegel-Moore, 2001). Significant ethnic differences emerged for bulimia, with Hispanic adolescents reporting the highest prevalence; there was a trend toward ethnic minorities reporting more binge eating, while non-Hispanic White adolescents tended to report more anorexia ( Swanson et al., 2011 ). However, for binge eating, other studies showed that risk factors did not include ethnicity but rather childhood obesity and familial eating problems in studies comparing Black and White women (Striegel-Moore et al., 2005). The variability that exists across studies is noteworthy and warrants further study.

   Contrary to earlier beliefs, a growing number of studies suggest that U.S. ethnic minority groups are trending toward higher levels of eating disorders and that the relationship between ethnicity and disordered eating may vary by disorder (Striegel-Moore, 2000; Striegel-Moore & Smolak, 2000; Cachelin, Striegel-Moore, & Regan, 2006). One study, for example, conducted in Minnesota among over 81,000 adolescents, found that the highest prevalence for disordered eating was among Hispanic and Native American teens of both genders (Croll, Neumark-Sztainer, Story, & Ireland, 2002). Quite often this trend is attributed to acculturation (i.e., how much they have adopted the values and behaviors of the prevailing culture). As minorities accept the dominant culture's values, they are subjected to the same kinds of pressures to be thin as their Caucasian counterparts. Findings by Davis and Katzman ( 1999 ) showed that in Chinese university students increased acculturation was associated with greater reports of bulimia and drive for thinness in females and greater perfectionism in males, both factors in distorted eating. Measuring the prevalence of eating disorders in minority populations is further complicated by the fact that they are underrepresented in most studies, and the likelihood that they will seek help/ treatment or be asked about eating disorder symptoms is poor ( Stein, 2000 ). The role that ethnicity plays in the development of distorted eating needs to be further studied ( Boisvert & Harrell, 2012 ;  White & Grilo, 2005 ; Striegel-Moore et al., 2005).

   Eating disorders (ED) occur more frequently in women; however, men are less likely to be diagnosed as they are often stereotyped as female disorders ( SAMHSA, 2011 ). Adolescent studies regarding lifetime prevalence estimates found no sex differences in the prevalence of anorexia or subclinical binge eating disorders, while for bulimia, binge eating disorder and subclinical anorexia prevalence was higher in girls ( Swanson et al., 2011 ). Just as was observed in minorities, eating disorders are increasing among males as they are finding themselves subjected to the same cultural ideals in regards to body image and social pressures that women face ( Boisvert & Harrell, 2012 ). For example, 10% to 15% of individuals with anorexia and bulimia are male, and among gay men, the numbers increase to 14% for bulimia and over 20% for anorexia ( Russell & Keel, 2002 ).

   Many believe that part of the problem with identifying men with eating disorders goes beyond stigma and underreporting to the very instruments used to assess eating disorders. Most of the commonly used measures of eating pathology (both self-report and interview-based) were developed and validated using all-female populations (Stice et al., 2004). And many focus on restricting behaviors as they are observed in women, which may or may not be similar in men ( Boerner, Spillane, Anderson, & Smith 2004 ). More research with male populations is needed as well as a better understanding of male-specific expressions of eating pathology. It is important to note that in some states (e.g., NJ, IL), as late as 2007, eating disorders were excluded from conditions considered to be serious mental illnesses (Klump, Bulik, Kaye, Treasure, & Tyson, 2009).

Social Support Systems

Individuals with eating disorders often report an unusual amount of disruption in their social and intimate relationships due to their symptoms. Anorectic clients frequently report avoiding social interactions with others where food is the focus of attention, fearing that their abstention from food will be noticed. Also, anorectic clients may spend a great amount of time thinking about food, cooking for others, exercising, and avoiding people who might sabotage their efforts to restrict their food intake.

   Bulimic individuals often hoard food, eat secretively, and purge in private, and therefore, frequently search for times to be alone. Bulimic clients also describe spending large amounts of time buying food, hiding food, eating and purging, and exercising.

   Persons with compulsive eating problems also avoid social activities and instead, purchase and consume large amounts of food. In sum, persons with eating disorders are often left with few friends. If the individual is involved in an intimate relationship, the person can experience difficulty maintaining the relationship while engaging in eating-disordered behavior.

   On the other hand, eating-disordered individuals often struggle to maintain social relationships in an effort to disguise the fact that they have a problem. Anorectic individuals may feel that friends are necessary ingredients to being “perfect.” However, as the eating disorder becomes more noticeable and severe, the person generally becomes more and more reclusive in the pursuit of thinness.

   Due to these pervasive feelings of isolation in individuals with eating disorders, group therapy has become a common treatment modality for such clients. Eating-disorder groups facilitated by a therapist with expertise in this illness can provide social support as well as other therapeutic benefits.

   For adolescents with eating disorders, it is highly recommended that families become involved in family therapy. Families are often resistant to treatment and must be educated about the nature of the illness and ways to cope with the teenagers' symptoms.

   For college-age students and adults, group therapy that focuses on the underlying reasons for the eating problems rather than issues about food can be very beneficial to clients. Group therapy can be both supportive and confrontive, thereby preventing the individuals from denying their symptoms.

   At nearly every large university health services center, there are resources available to men and women with eating disorders. There are also a number of Internet resources that provide information and referral sources for eating-disordered clients, such as the following sites:

·   www.aedweb.org : The Academy for Eating Disorders is a global professional association committed to leadership in eating disorders research, education, treatment, and prevention.

·   www.anad.org : The National Association of Anorexia Nervosa and Associated Disorders (ANAD) is a nonprofit organization dedicated to helping individuals with eating disorders and their families. It provides hotline counseling and referrals to support groups and health care professionals. ANAD publishes a quarterly newsletter as well as educational materials and will provide educational speakers, programs, and presentations for schools, colleges, public health agencies, and community groups.

·   www.eatright.org : The world's largest organization of food and nutrition professionals that is committed to improving the nation's health and advancing the profession of dietetics through research, education, and advocacy including information on eating disorders.

·   www.mentalhealthscreening.org : Screening for Mental Health, Inc. (SMH) is a nonprofit organization that coordinates mental health screening programs nationwide, including the National Eating Disorders Screening Program (NEDSP), a large-scale screening for eating disorders, and Interactive Telephone Screening Programs. NEDSP includes an educational presentation on eating disorders, body image, and nutrition, a written screening test, and the opportunity to meet one-on-one with a health professional.

·   www.namedinc.org : The National Association for Males with Eating Disorders' (NAMED) mission is to provide support to males with eating disorders, to educate the public on the issue, and to be a resource of information on the subject.

·   www.nationaleatingdisorders.org : The National Eating Disorders Association (NEDA) is the largest nonprofit organization in the United States dedicated to eliminating eating disorders. NEDA advocates on behalf of individuals and families affected by eating disorders and offers prevention programs, educational materials, research, and a toll free referral hotline.

·   www.nimh.nih.gov : National Institute of Mental Health's (NIMH) mission is to transform the understanding and treatment of mental illnesses through clinical research. Information on eating disorders can be found under the health and education tab.

·   www.overeatersanaonymous.org : Overeaters Anonymous (OA) is an international, nonprofit organization that provides a worldwide network of volunteer support groups. Modeled after the 12-step Alcoholics Anonymous program, the OA recovery program addresses physical, emotional, and spiritual recovery aspects of compulsive overeating.

Elimination Disorders

In the DSM-5, Elimination Disorders form a separate cluster of symptomatology that is most commonly first diagnosed in children under the age of 18 years. However, the onset of elimination disorders can occur during any developmental period and is often accompanied by environmental or social stressors. There are two types of elimination disorders: primary and secondary. The primary type is designated when the child has never accomplished a pattern of continence for a period of time. The secondary type is diagnosed if the child had accomplished a pattern of continence before developing urinary or fecal incontinence. Enuresis occurs when the child, who must be at least 5 years old, urinates in clothing or bedding repeatedly and frequently (2 times per week) over the course of at least a 3-month period ( APA, 2013 ). In addition, the diagnosis of enuresis can be accompanied by the following specifiers: “nocturnal only, diurnal only, or nocturnal and diurnal” ( APA, 2013 , p. 355).

   Encopresis occurs when the child, who is at least 4 years old, has frequent and repeated bowel movements over a period of 3 months. In both cases, the pattern of behavior may be voluntary or involuntary ( APA, 2013 ). Specifiers for this disorder include: “with constipation and overflow incontinence” and “without constipation and overflow incontinence” ( APA, 2013 , p. 358).

   In both cases, it is important for the helping professional to refer the child and family to a physician for consultation since the problem may be medical in origin. Certain medications can cause constipation in a child and bowel movements may have become painful. On the other hand, environmental or social stressors may also result in enuresis or encopresis in children. Both types of elimination disorders more commonly occur in males than females.

Differential Diagnosis

A diagnosis of an eating disorder should be weighed against the possibility that a client has another medical condition that could lead to severe weight loss such as Crohn's disease, hyperthyroidism, or HIV/AIDS. A client with Major Depressive Disorder may experience weight loss due to a lack of appetite but does not have a fear of gaining weight or a body dysmorphic condition. Schizophrenia can result in odd eating behaviors and preferences, but the symptoms of an eating disorder are not present. Likewise, clients with diagnoses of social anxiety (particularly fear of eating in public), obsessivecompulsive disorder, or body dysmorphic disorder may have symptoms that are similar to eating disorders; however, they do not possess the fear of gaining weight nor do they meet the full criteria for any of the eating disorders ( APA, 2013 ).

Case 11.1

Identifying Information

Name: Greg Deal

Age: 24 years old

Ethnicity: Caucasian

Educational Level: Graduate student in law school

Marital Status: Single

Background Information

As a counselor at the student health center at a large university, you see many young men and women who have concerns about their self-image, self-confidence, and problems related to depression and anxiety. You work primarily with young adult GLBTQ men and women who have come voluntarily to the Out Youth center on campus. The center serves all students at the university who are gay, lesbian, bisexual, transsexual, or who are questioning their sexual orientation. The center provides individual counseling, group therapy, crisis intervention services, psychoeducational seminars, and resources and referral information. Students can access services free of charge. The center has an intake worker who gathers basic information about the student and sets up appointments with the therapists.

Intake Information

Greg Deal called the student mental health clinic and requested an appointment with a therapist due to feelings of depression, difficulty completing his schoolwork, and ongoing eating problems. He told the intake worker that he has been experiencing the current problems for approximately 1 month. He stated that he has been having difficulty getting himself to classes, can't concentrate on his homework, feels drained of energy, and wants to do nothing but sleep all day.

Initial Interview

During the first appointment with Greg, you gather information about the history of the presenting problem, a social history, and a family history. The first session is 90 minutes in duration in order to obtain enough information to make an initial assessment.

   Greg is a noticeably thin, tired-looking young adult male who is curled up in a chair in the waiting room when you meet him. He is wearing a pair of baggy blue jeans, a long-sleeved shirt covered by a heavy sweatshirt, and heavy socks and sneakers, despite the fact that it is July. His hair is tousled as though he forgot to brush it after getting up in the morning. You notice that he has very dark circles under his eyes, and his face, including his forehead, appears bony.

   Greg states that he developed an eating problem 7 years ago at age 17 after graduating from high school as class valedictorian and gaining admittance into a prestigious university in Boston. Prior to the eating problem, he weighed approximately 160 pounds and was 5'10” (an ideal weight for his height and age). Greg moved away from home into the dorms at school and began limiting his food intake to only vegetables and exercising, sometimes 4 hours a day.

   Initially, Greg lost about 20 pounds and found he couldn't lose any more weight without further restricting his diet. He started eating very small quantities of food, counting the number of bites he could have each day. At one point, he allowed himself only 4 bites of food per day. If he ate more than that, he would make himself exercise an extra hour.

   Greg reports that by spring break of his first year, he weighed only 120 pounds. His BMI was less than 16.0 kg/m2. When he went home to visit, his parents were shocked at his appearance and took him to his old physician. He managed to convince the doctor that he did not have anorexia and that he had simply lost his appetite because of the pressures at school. The physician recommended that he drink three cans of Ensure each day in order to bolster his weight. Greg was unwilling to do this because of the high calorie content of the drink. Assuring his parents that he would eat, he returned to school. He refused to think he had a problem; rather, he just wanted to lose weight and be popular. He felt that he had always been characterized by his peers as a bookworm, and he desperately wanted to “fit in” at college.

   He states that on one occasion he was rushed to the hospital by ambulance after fainting in class. He stayed at the hospital for a week due to dehydration and electrolyte imbalance. He begged his parents to allow him to finish the semester since it would “ruin my grade-point average” not to complete the classes. At that time, he got his weight up to 125 pounds to “prove” he didn't have an eating disorder.

   Later, he lost weight again, and his weight has hovered around 115 pounds since that incident. Greg states that he has been hospitalized on five different occasions over the past 7 years for dehydration, exhaustion, electrolyte imbalance, and starvation/emaciation. He has rarely seen a counselor for more than a few sessions, stating, “They just thought I should start eating and that would resolve the problem.”

   Due to his eating problems, his heavy school schedule, and his exercise regime, Greg reports that he has had little time for “having fun.” He states that he had a boyfriend for about a year, but he couldn't handle his problems with food.

   Currently, Greg weighs 118 pounds and feels “heavy.” He considers his ideal weight to be 113 pounds. He suggests that he can “see fat” on his thighs and stomach when he weighs more than 113 pounds. Due to the 5-pound increase in his weight, Greg has recently begun to use laxatives and occasionally induces vomiting, although he states that it hasn't helped him lose weight. He feels very anxious because he thinks he has lost control of his eating, at times bingeing on ice cream and chocolate bars when he gets extremely hungry. Greg does admit that he thinks he may have an eating problem.

Family Session

After you have met with Greg on three occasions, he tells you that his parents are coming for a visit. You ask Greg if they would be willing to come to a session with him and he agrees to ask them. Greg appears to have developed a working relationship with you. He has kept his scheduled appointments and has been on time for them.

   The session with Greg and his parents lasts approximately 1 hour. It is apparent from the beginning of the session that certain dynamics prevail in this family. Greg, who has previously been very articulate and insightful in individual sessions with you, becomes quiet, unassertive, and passive during the family interview.

   His mother makes numerous attempts to speak for Greg and appears aggressive and overbearing. She admits that she herself has dieted most of her adult life in order to “stay fit,” but that she thinks Greg is overdoing it a bit. His father, on the other hand, appears passive and emotionally distant. He does not speak unless he is asked a question or spoken to directly. He often glances at his wife while offering his opinion about the family situation. He does suggest he is very concerned about Greg's problems.

   Greg's mother states that Greg has always been the “perfect” child—an overachiever, a straight-A student, president of the student council, and an exceptionally well-behaved adolescent. “We never had any problems like other parents have with their teenage children,” she states proudly.

   As his mother speaks, Greg becomes increasingly uncomfortable, despondent, and withdrawn. He curls up in his chair as a small child might. It is apparent that Greg disagrees with his mother's description of his life at home. When you ask him how he is feeling at the moment, Greg replies, “Oh, yeah, everything was just great as long as we all agreed with Mother and her opinions, never letting anyone else have a say-so in anything. Then, Dad would get real quiet for a while until everything just blew up and all hell would break loose. Yeah, it was perfect all right.”

   At this statement by Greg, his mother becomes extremely angry, saying that he cannot continue the session. You calm the situation by discussing the importance of not talking for other family members and of using “I statements” when speaking about feelings. Although you are able to establish some order, it is obvious that the family will need additional counseling related to communication and family functioning. The family is clearly enmeshed and needs to see the value of Greg becoming an independent adult in his own right.

· 11.1–1 What are some of Greg's strengths?

 

· 11.1–2 With whom would you want to consult in order to ensure that Greg receives the best possible treatment?

 

· 11.1–3 What resources might be beneficial to Greg?

 

· 11.1–4 What issues would you want to include in a contract with Greg?

 

· 11.1–5 What is your diagnosis for this case?

 

· 11.1–6 Are there any physical or general medical conditions that may affect diagnosis?

 

· 11.1–7 What subtype, severity, and course specifiers would you want to use?

 

· 11.1–8 What psychosocial (V codes/Z codes) and contextual factors including cultural may affect diagnosis and treatment?

 

· 11.1–9 What characteristics make this individual more vulnerable to suicide?

 

Case 11.2

Identifying Information

Client Name: Maria Lopez

Age: 16 years old

Ethnicity: Hispanic

Educational Level: 11th grade

Intake Information

The intake worker received a phone call from the mother of Maria Lopez, who had been referred by her physician, Dr. Amanda Welby, for mental health therapy. Maria's mother stated that Maria has been having problems with eating for the past 9 months and seems depressed and withdrawn much of the time. She has been seeing her physician every 3 months for physicals and weight checks. She is 5 feet 7 inches tall, and her current weight is 102 pounds. The problem has persisted despite Maria mother's efforts to ameliorate the situation. Maria was discharged 1 week ago from the hospital after being admitted after a fainting spell. She was treated for dehydration.

Initial Interview

Your initial interview with Maria Lopez lasts 90 minutes. During that time you obtain information concerning the presenting problem, a social history, and a family history. You establish rapport with the client, discuss issues of confidentiality, and schedule another appointment with her. In your files you have made the following reports.

Presenting Problem

Maria Lopez is a 16-year-old Hispanic female who came to the Eating Disorders Clinic at her family's request after being hospitalized for a fainting and dehydration episode. Dr. Amanda Welby referred her to the clinic over concerns about the client's weight loss over the past 9 months.

   Maria stated that she doesn't think she has an eating problem, although she admitted to wanting to lose weight to look more like the other girls at school. She stated that she used to be overweight at 130 pounds (although 130 pounds would be an ideal weight for someone 5 feet 7 inches tall). She stated that being overweight gave her low self-esteem and that she didn't feel that she “fit in” with the other girls.

   She reported that she has been trying to lose weight since she was 13 years old and had tried several diets but never seemed to lose much weight until recently. During the past school year, Maria began skipping breakfast and lunch. For dinner, she primarily ate broiled chicken and salad. She stated that eventually she was able to eliminate the salad and eat only a piece of boneless, broiled chicken each day. She has found that she can lose weight rapidly on this sparse diet.

   In response to a question about her exercise regime, Maria stated that she started walking 30 minutes a day about a year ago. After a month, she began running about 3 miles a day, which quickly escalated to running approximately 10 miles a day. She also begged her parents for a stationary bike that she exercises on approximately 2 hours a day. “Sometimes, if I can't fit all the exercise in during the day, I wait until my parents go to sleep at night and get up and work out on the stationary bike until 1 A.M.”

   Maria admits to being very tired and having no energy. She states that sometimes it is exhausting to exercise, but she feels that she has to in order to lose more weight.

   When asked what she thinks of her weight now, she replied that she would like to lose a few more pounds because weighing less than 100 pounds is her goal.

   Maria stated that she is not having problems in school and that she is a straight-A student. She hopes to get a scholarship to Princeton, Yale, or Harvard University, and she has been studying hard for the SAT exams.

Social History

Maria stated that she has always liked school and has done well throughout her school experience. She also plays the violin in the school orchestra, is in the choir at her church, belongs to a chess club, takes art lessons, and dancing. She stated that her parents never let her sit around and watch TV; she is always busy doing something.

   She has a few good friends but not a lot of friends. “I guess I'm kind of shy, and people sometimes mistake that for being snooty,” she told you.

   Maria appeared embarrassed when you asked her if she's had any boyfriends. She stated that because she was overweight, none of the boys in her class really liked her. About a year ago, she overheard a boy talking to her best friend in the cafeteria at school say that if she just lost a little weight in her thighs, she'd be quite pretty. Maria stated that she's always felt left out of a really popular group of girls at school because she doesn't have a boyfriend. “They get together and go out to a movie or for a pizza and never invite me because I don't have a boyfriend to go with.”

   Although she is not in the most popular group, Maria stated that she was always so busy with other activities that it didn't really bother her until this past year. She said she has always had one or two good friends with whom she engaged in activities and who also took dancing and art or played the violin. During the past year, however, her good friends have become involved with boys, thus leaving Maria out of their group.

Family History

Maria stated that her family is very close. Maria has a younger brother, Juan, age 14, and an older sister, Carla, who is 20 and away at college most of the time. Her father works at a factory that makes electronic parts for computers and often works double shifts. Her mother is a homemaker and does volunteer work for the school and church.

   She said that her mother is always bugging her about her eating. Maria felt that her mother has an eating problem also, but would never admit it. “My mother is a very controlling person and has always watched over me like a hawk whenever I put a bite of food in my mouth,” said Maria. “I'm either eating too much or too little. I can never seem to please her.”

   Maria said that her mother is a foodaholic and has always been pushing food at Maria as long as she can remember. Maria described her mother as being of average weight but a little on the heavy side. “She is always cooking and expects everyone in the family to eat more than one plate of food for every meal.”

   Maria described her sister, Carla, as “nothing like me. She's real social and has lots of friends and doesn't care what anyone thinks about her.” She stated that her sister is also slightly overweight but not obese. Maria described her brother as just a normal boy. He plays soccer and doesn't really care much about school but does okay, with about a B average.

   Maria said that she doesn't feel very close to her father since he is gone so much. Without prompting, she related an incident in which her father stated that Maria is “his little princess” and he wishes she would never grow up. It was apparent that Maria was upset by that remark. When asked if the remark bothered her, Maria replied that she doesn't know how she can stay little all her life when she is growing up and it is out of her control.

   During the past year, Maria's relationship with her parents has grown tense due to her losing so much weight. “They are constantly telling me how, when, and where to eat, and if I don't, they get upset.” She also stated that “being the middle child and always having to live up to their expectations is not easy all the time.”

   When asked about arguments at home, Maria said that everyone argues at home but it doesn't mean anything. “My family is just highly emotional and scream and yell at each other but it doesn't mean they don't love you. I just don't like to listen to it so I go to my room and study.” When asked if she thought she was angry about anything, Maria replied that she never really gets angry and that she doesn't like conflicts with anyone.

· 11.2–1 Briefly describe what you think are Maria's strengths.

 

· 11.2–2 What are some of the contributing factors (V codes/Z codes) that seem to be involved in Maria's problems with food?

 

· 11.2–3 Are there diagnoses that you would want to rule out? If so, what are they?

 

· 11.2–4 What is your diagnosis for this case (any subtype, severity, and course specifiers)?

 

· 11.2–5 What would be some resources that you could suggest to Maria and her family that would assist them in Maria's recovery?

 

· 11.2–6 What cross-cutting symptom measures would you use from Section III of the DSM- 5?

 

Case 11.3

Identifying Information

Name: Karen Black

Age: 17 years old

Ethnicity: Caucasian

Educational Level: 12th grade

Background Information

Karen Black decided to enter counseling after an initial intake session where you assessed her as having low self-esteem and a possible Major Depressive Disorder. During the initial intake, she told you that she is going off to college in the fall and that she just doesn't feel good about herself anymore. She stated that she has never felt she is very pretty; however, it didn't really bother her that much until this year, her senior year at Golden High School.

   Karen appears to be an attractive girl of average weight and height. She stated that her parents are divorced. She lives with her mother and two younger brothers, Mike, age 15, and Scott, age 13. Her parents divorced about 2 years ago, and her father lives in an apartment on the opposite side of town. Karen gets along well with both parents although she confessed that the year her parents separated was chaotic. Her mother accused her father of seeing another woman. Karen doesn't feel that allegation was true although she thinks her father may be dating someone else now.

First Session

After you discuss issues of confidentiality, Karen tells you that her biggest problem is being worried about going to college and nobody liking her there. She feels like the “ugly duckling” at school and doesn't have a boyfriend. She has had boyfriends in the past and just recently broke up with someone she says was more of a “friend” than a “boyfriend.”

   Nevertheless, it bothers her to have no one to call on the phone or go out with, and the loss of the relationship with her boyfriend makes her feel even worse about her already poor self-image. With some pride, she tells you that she is a straight-A student and has received a scholarship to Golden State University for the first year of college. She indicates that she doesn't like sports and isn't athletic, but she does ride bikes with her brothers occasionally and enjoys walking her golden retriever, Nugget.

   Karen thinks that she and her mother have a good relationship. However, Karen states that her mother is always nagging her about what she wears, how she fixes her hair and makeup, and what she eats. She likes to go shopping with her mother, and sometimes they go to lunch and a movie when her mother isn't working. Her mother is a buyer at a large department store, Canary's, at one of the malls and often has to work on the weekends or go on buying trips for 3 or 4 days during the week. Karen is expected to stay home and take care of her brothers when her mother is gone.

· 11.3–1 At this point, what are the issues that you consider important in assessing Karen?

 

Second Session

Karen arrives on time for her second session with you after school on Wednesday at 4 P.M. She appears happy to see you when you go to the waiting room. She is wearing blue jeans and a pink top. You notice she has dark circles under her eyes and looks very tired. You mention that she looks fairly tired today, and she shrugs her shoulders and says that she had a term paper due that she worked on late the previous night.

   She sighs and says, “Everyone has been telling me that I look tired, and I don't really know why they keep saying that. It makes me feel really selfconscious.” When you tell her that she has dark circles under her eyes, she says, “Oh, that's nothing to be worried about.”

   You decide to summarize the first session with Karen and continue your assessment of her situation. You discuss her parents' divorce, her scholarship to college, her fears about attending the university in the coming school year, and her concerns about her self-image.

   “Is there anything I left out from our discussion last week?” you ask.

   “That's probably all we talked about, since I'm scared to tell you the rest of it,” Karen replies.

   “What do you think is making you scared to tell me something?” you respond.

   Karen looks despondently out the window. “I'm just afraid you'll think I'm dumb or weird or crazy or something if I tell you. It's something that's really been bothering me lately, and I just don't feel like I can talk to anyone about it.”

   You remind Karen that anything she tells you will be kept confidential, unless it's about harming herself or someone else, and that you are there to help her work on issues that are bothering her. She sits quietly for a few moments staring out the window and then begins talking in a quiet, measured voice.

   “Well, I told you I feel really bad about myself and how I look, and I feel like everyone thinks I'm just an ugly, overweight, boring person to be around. So, for about a year, I've been trying to lose weight. At first, I went on all these crash diets, and I'd lose a few pounds, but then I'd gain it right back because I'd get so hungry I'd eat everything in sight. It was really frustrating to me because I had this friend who lost about 20 pounds and everyone was saying how good she looked, and she kept saying all I had to do was exercise more and I'd lose weight, too. Well, I tried that for a little while, but I hate running and quit after about a month. While I was in one of my starvation phases, my former boyfriend asked me out for pizza one night. I went and sat there with a glass of tea. He asked me why I wasn't eating, and I lied and said I wasn't hungry. He told me I'd look good the way I was if I'd just lose a little weight in my thighs. That comment was mortifying to me. I don't know what happened, but I sat there and ate almost a whole pizza and when I got home, I just stuck my finger down my throat and threw it all up. I was so angry with him for saying that to me. The next day I got on the scale, and I had lost 2 pounds. I felt so good about having lost 2 pounds that I decided maybe I could eat and lose weight at the same time by, you know, throwing up. It sort of got me on a cycle. For a while, I tried to eat one meal a day like I'd been doing, but it got harder and harder not to binge. So, I would binge in the afternoon when my mother was at work, and then I'd vomit it all up. It's just gotten to be a vicious cycle.”

   “Karen, I don't think you're weird or crazy. A lot of girls your age have problems feeling good about themselves and their bodies. From what you're describing, it sounds as if you're struggling with food and body image. I'd like to ask you some specific questions about these issues if it's okay with you.”

   Karen shrugs her shoulders and says, “Okay, I'm sort of glad I've finally told someone.”

   “What do you mean by binge? Tell me a little bit about what you ate when you ‘binged,'” you ask.

   “Huge amounts of food,” Karen responds. “I mean everything I could get my hands on. It was like this uncontrollable urge that I just couldn't stop. For example, a few weeks ago when I broke up with my boyfriend, I went home after school and ate a whole box of chocolate cookies, a carton of ice cream, three Hostess Twinkies, two candy bars, and a peanut butter and jelly sandwich. Then, I was thirsty so I made about a quart-sized glass of frappuccino. After that, I felt so bad about myself, I just went into the bathroom and threw it up. It sounds terrible, I know, but I felt better afterward.”

   “It doesn't sound terrible, but it does sound like a problem for you. How often does this happen, Karen?” you ask.

   “It started out just like once a week,” Karen replies. “But now, I do it every day, sometimes two or three times a day. Sometimes, I feel like I've vomited so much, I can't vomit anymore. So then I take laxatives.”

   At this point, you decide to ask about Karen's feelings before, during, and after a bingeing and purging cycle. Karen tells you that she usually gets an uncontrollable urge to eat a lot of food and tries to distract herself with other things to do until it becomes unavoidable. She then begins looking for ways to obtain the food without her mother noticing. She sometimes goes out to fast-food restaurants and buys food so her mother won't wonder where all the food went. She then finds a secluded place to eat it—either in her car or her bedroom— and then finds a place to throw up.

   “I'm so nervous someone's going to walk in on me when I'm vomiting. It almost happened a couple of times when I got sick at school. I went into a bathroom that no one ever uses, and a teacher walked in right after I had thrown up. I told her I wasn't feeling well and needed to go home. She sent me to the main office to get a permission slip to leave. I was so embarrassed.”

   “How long ago did this problem start?” you inquire.

   “About 6 months ago, I guess,” Karen sighs. “It's been a roller coaster ever since. The worst part about it is that I feel better after I get rid of the food, so I can't seem to make myself stop.”

   You ask Karen if she thinks her mother is aware of the problem with food that she has been having. Karen thinks her mother has some idea but hasn't said anything to her. She has asked Karen about missing food at times and wonders out loud what happened to it. Karen feels extremely guilty when her mother questions her but avoids telling her the truth about the food.

   “I just don't know what I'm going to do. I don't want to go to college with this problem. Everyone will know something's wrong with me. I just don't know what to do about it.”

· 11.3–2 How concerned are you about Karen's medical status? Explain why you would or would not involve a physician.

 

· 11.3–3 What are some of Karen's strengths?

 

· 11.3–4 From this assessment, what would be your diagnosis for Karen?

 

· 11.3–5 What severity and course specifiers would you want to use?

 

· 11.3–6 What psychosocial (V codes/Z codes) and contextual factors including cultural may affect diagnosis and treatment?

 

· 11.3–7 What characteristics make this individual more vulnerable to suicide?

 

· 11.3–8 What are some resources that might help Karen cope with these issues?

 

Case 11.4

Identifying Information

Client Name: Laurel Jackson

Age: 48 years old

Ethnicity: Caucasian

Marital Status: Married, no children

Occupation: Middle school math teacher

Intake Information

Laurel Jackson, a 48-year-old schoolteacher at a large metropolitan public school, makes an appointment to see you for counseling at Community Mental Health Center. The intake form states that she has a college education, is married, and has no children. Under the heading “Presenting Problem,” the intake worker has written, “The client stated on the phone that she is concerned about problems she has had with her recent eating habits.”

Initial Interview

Upon meeting Laurel for the initial interview, you notice that she appears to be older than her stated age of 48. She is a petite woman, approximately 5 feet 3 inches tall. She has gray hair that is pulled back in a bun, and she is dressed rather conservatively in a black skirt, a pink blouse with lace around the collar, and a black cardigan sweater. She appears to be of average to slightly above average weight. She smiles cordially and carries on small talk about the traffic getting to the agency while she gets settled in your office.

   You explain your position as a counselor at the agency and issues of confidentiality. Then, you ask her what had brought her to the agency. She states that she was referred to you by a physician, Dr. Miller, at the hospital across the street from the agency. She explains that she had been in a program called “Mediquik” at the hospital for the past 3 months. The program is designed for persons who are more than 30 pounds overweight. It involves a liquid diet for optimal weight loss. Participants are medically supervised during weekly group sessions at the hospital.

   She explains that over the past 3 months she has lost 85 pounds. “I weighed over 200 pounds when I started the program, and you can imagine how awful I must have looked since I'm such a short person. I felt really good about losing all that weight.”

   You ask her if she was allowed to eat any solid food on the diet, and she states that it is a completely liquid diet that involves three liquid supplements per day, water, and nothing else.

   You comment that a strict diet like that must have required a great deal of willpower, and Laurel states that initially it was very hard, but that after a couple of weeks, she got used to not eating and it got easier. Laurel stuck to the diet religiously for the 12-week period of time. After 12 weeks the hospital gave her an eating plan that consisted of solid food for a week, and then the program was over.

   Laurel states that recently she finds herself getting up in the middle of the night and eating huge quantities of food, especially carbohydrates, and then feeling so sick the next morning she has a hard time getting to school on time. She says that no matter what she does, she can't seem to stop this midnight bingeing, and she is beginning to panic because she has begun gaining weight.

   “I'm so scared I'll gain all the weight back that I lost that the other night, after I went on a major binge and ate everything in the house, I forced myself to throw up. It actually made me feel better, so the next night, I binged and then vomited again.” Laurel states that she knows this behavior isn't healthy and that's why she decided she needs some help.

· 11.4–1 What other information would you want to obtain from Laurel before you could make a comprehensive assessment and diagnosis?

 

   You decide that you need more information about Laurel's personal and professional relationships. You ask her about her family, especially history of binge eating and obesity.

   Laurel states that she has been married for the past 8 years. “I've known Darin since high school. He went into the Navy after school and got married. He came back home after a divorce about 12 years ago. I didn't think I'd ever get married, but Darin and I just hit it off. He has two daughters who are grown and on their own now. So it's just the two of us at home.”

   Laurel states that her relationship with Darin is very good. Darin works at a local grocery store chain as a manager and sometimes works long hours, but they usually have time together during evenings and weekends. She states that Darin is very proud of her for losing so much weight but never pressured her about being overweight.

   Laurel states that her 80-year-old mother lives in the same neighborhood as she does. She talks to her mother every day on the phone and visits her after school three or four times a week. She says her mother has lived in the same house for the last 50 years. Laurel states that her younger sister is married, has three children, and lives in another state. Laurel's father died 10 years ago, so she feels a need to take care of her mother now.

   When you ask Laurel about the quality of her relationship with her mother, she states, “Mom and I are a lot alike. She has always had a weight problem, too, although since she's gotten older she's slimmed down. To my mother, food was love. She always cooked big meals for our family. We always had big breakfasts and lots of desserts. I was overweight when I was 5 years old! My whole family was obsessed with food, and I'd get stuck on one certain kind of food and eat it every day.”

   Laurel's last statement strikes you as unique, and you decide you want more information about her desire to eat the same food every day. You say, “So, you wanted to eat the same thing every day?”

   “Oh, yes,” Laurel sighs. “Once I ate nothing but potatoes for an entire year. Then, I switched and I ate nothing but spaghetti for another year.”

   “So, you got stuck on one kind of food and ate nothing but that specific food every day?” you query.

   “For lunch and dinner, every day, for an entire year, like I was obsessed with it,” Laurel states while rubbing her forehead. “I haven't gotten stuck like that on one kind of food since I got married because Darin likes regular meals and can eat anything without gaining weight,” Laurel states with a deep sigh.

   You suggest to Laurel that food has been problematic for her for a long time. She explains that she feels food has been “the enemy” ever since she can remember.

· 11.4–2 What are some possible emotional problems you would want to rule out in assessing Laurel's situation?

 

   You ask Laurel if she has noticed any changes in her mood recently. She tells you that she has been upset about gaining back some of the weight she lost but that she is normally a fairly happy person.

   You ask her if there is anything going on in her life that has been making her feel anxious lately. Laurel states that at the end of the school year, she always has a lot of work to do at school. You decide to get more information about Laurel's job.

   “Do you teach specific classes or grades at school?” you inquire.

   Laurel replies that she teaches sixth-, seventh-and eighth-grade math, including general math and Algebra I. “I have been teaching math for 27 years now,” Laurel states proudly. “I really love math, but at the end of the year, I am in charge of a County Math Fair that I developed about 5 years ago. It involves middle schools from all over the county. There are over 1,500 students and parents involved in this week-long event. I'm in charge of the whole thing, and it just stresses me out. I tend to be a perfectionist about my work, and I worry all the time about being prepared for classes and getting all the homework assignments graded. I want my students to see how fun math can be, so I work very hard at making my classes interesting.”

   Laurel states that she tends to work nights and weekends on her classes. “I have a hard time relaxing. Darin and I play bridge on Saturday nights with some friends, but we don't do much else. Darin and his brother go fishing on the weekends, and I usually stay home and work. Sometimes we go out to eat.”

· 11.4–3 What are some of the strengths that Laurel has mentioned in the session?

 

· 11.4–4 What are some resources in your town that might be beneficial to Laurel?

 

· 11.4–5 Laurel's husband, Darin, comes to a session with Laurel. What are some questions you could ask Darin that might benefit Laurel in therapy?

 

Case 11.5

Identifying Information

Client Name: Miguel Hernandez

Age: 10 years old

Ethnicity: Hispanic

Educational Status: 5th grade at Jones Elementary School

Intake Information:

Miguel Hernandez is a 10-year-old Hispanic male in the 5th grade at Jones Elementary School. He has a younger brother, Joseph, age 8. His mother, Michaela Hernandez, and father, Carlos Hernandez, are divorced and Miguel and his brother live with their mother in Houston. Miguel has had a history of anxiety and is currently on medication. His mother contacted the school counselor who referred the family to Houston Mental Health Center with concerns that Miguel may have an eating disorder. The intake worker stated that Miguel has lost a significant amount of weight during the past year. You are a therapist at the mental health center and have been assigned this case. You determine that it would be beneficial to meet with Ms. Hernandez prior to your assessment of Miguel.

Initial Interview with Ms. Hernandez:

You meet Ms. Hernandez in the waiting room and you notice that the child care intern is encouraging Miguel to play a board game with her. Miguel is curled up in a chair looking unsure about whether or not to play. You introduce yourself and suggest that Miguel play with the child care intern while you talk with his mother. He reticently goes to the table where the game is being set up by the intern. You smile and tell Miguel where his mother will be and that you will be back in half an hour to talk to him. You notice that Miguel's sweatshirt and pants look three sizes too big for his slight frame.

   Ms. Hernandez follows you to your office and takes a seat next to your desk.

   “So, Ms. Hernandez, the intake worker told me that you have been having some concerns about your son, Miguel. Can you help me understand what you've been worried about lately?” you suggest.

   “Oh, please call me Michaela. I have been tearing my hair out with worry about Miguel. He is getting so thin and I tell him he needs to eat so he can be strong, but he just plays with his food and doesn't eat enough. I don't know what to do. I have tried making his favorite foods and giving him extra helpings but he just doesn't seem interested. If I push too much, he cries and runs out of the room. Last week, he told me he just doesn't like to eat because he's afraid he'll get sick to his stomach, but when I told him that wouldn't happen, he just said, “how do you know?” I'm afraid he's got that anorexia.

   “Okay, so can you give me an example of what he eats in a given day?” you inquire.

   Michaela thinks for a moment and then replies, “Well, last Sunday, for breakfast he ate half a pancake and some juice before we went to church. He came home and when I asked him what he wanted for lunch he said, “nothing,” but I made him and his brother a sandwich and he only ate two bites and then said he couldn't eat anymore. For dinner, I made tacos because we were going to a potluck supper at church and I don't think he ate anything at all. He drank some lemonade but I didn't see him eat.”

   “How long has this been going on?” you ask.

   “Oh, let me think, I guess about 6–7 months. He got sick last winter with a bad case of the flu and was vomiting for a couple of days. I was very concerned that he was getting dehydrated so I made him drink a lot of fluids. I think it really upset him that he couldn't eat and was throwing up so much. But when he got better, he wasn't eating much. At first, I thought it was just because he was getting over the flu, but when it kept going on and on, I realized he just wasn't eating. He says he doesn't want to eat and it seems like he only wants soft stuff like ice cream or juice. Sometimes, he'll eat a little cereal or mashed potatoes but he doesn't want to eat anything that he has to chew.”

   “That must be very hard for you. Do you know how much weight he has lost?” you inquire.

   “Miguel wasn't a big boy before he got sick but now he's skin and bones. I think he's lost 15 or 20 pounds,” Michaela replies. “I bet you think I'm a bad mother but I've tried to get him to eat. I said to him, Miguel, you're getting too skinny and he just shrugs his shoulders and says I know I'm thin but I'm not hungry.”

   “Okay, so he doesn't seem to be worried about being overweight or too heavy?” you query.

   “Oh no, I think he knows he's really thin and I even think kids at school have said things to him, like you're going to blow away if you don't eat more,” Michaela says with a worried look on her face. She wrings her purse straps in her lap and says, “I just don't know what's wrong with him.”

   “How does Miguel get along with other students at school?” you ask.

   “Oh, he has lots of friends that he has grown up with in our neighborhood that he goes to school with,” Michaela responds. “Maybe, Miguel is one of the leaders in his class. He's always bringing friends over to the house after school because a lot of mothers work and I take care of them. Everyone likes Miguel.”

   “What has his mood been like during the past 6 months?” you inquire.

   “Miguel is a happy kid most of the time. But when it comes time to eat, he gets real quiet and gets an unhappy look on his face. Sometimes, he just blurts out that he wishes he never had to eat again.”

   “How does he get along with his dad?” you ask.

   “Oh, I suppose he gets along okay but his dad doesn't come around very often. You know, he's always working and has a new wife. Sometimes, I wonder if Miguel's problem is because he never gets to see his dad.”

   “Does he frequently ask about his father?”

   “Every once in a while,” Michaela says wistfully.

   “How about his brother? How does he get along with Joseph?” you ask.

   “Miguel is a good older brother. Sometimes they fight but I think that's normal, don't you?” Michaela states.

   “Absolutely, it sounds like they get along most of the time,” you respond. “Is there anything else you are concerned about?”

   Michaela thinks for a minute and says, “No, I'm mostly concerned about his eating and weight loss.”

   “OK, why don't we go get Miguel and talk for a few minutes with him.”

Interview with Miguel

Miguel comes into your office and sits down in the chair next to his mother. You ask about the game he was playing and he brightens up and says, “I won two times!”

   “Fantastic,” you reply. “You must be an expert at Angry Birds.”

   Miguel smiles and looks at his mother.

   You move your chair closer to Miguel and say, “Your mom tells me you don't like to eat much. Can you help me understand why you don't want to eat?”

   Miguel looks down and swings his legs and replies, “I don't like the way it feels.”

   “Do you mean how it feels inside your tummy or how it feels in your mouth?” you ask.

   “I don't like the way it feels in my tummy or my mouth,” Miguel states without hesitation.

   “Is there any kind of food you like?” you inquire.

   “Sometimes, I like ice cream,” Miguels suggests.

   “What's your favorite flavor?” you ask.

   Miguel puts his finger to his head and says, “Vanilla.”

   “Is there anything else you like to eat?” you question.

   “No, not really. I don't like to eat much,” says Miguel.

   “OK, see that mirror over there in the corner? Why don't you go stand in front of it and tell me what you see in the mirror.”

   Miguel gets up and moves in front of the mirror. He turns from side to side and then says, “I wish I could fit in my clothes” as he pulls his pants out from his waist. “I think I'm as thin as my brother.”

   “How does that make you feel?” you ask.

   “I don't really like it much because all my friends tease me.”

   “What do you do when your friends tease you?” you ask.

   “I just tell them that if they want to come to my house they'll stop it,” replies Miguel.

   “And if they don't stop teasing you?” you ask.

   “One time, I pushed a girl away because she kept saying “baggy pants” over and over again and she wouldn't be quiet.”

   “How is school going this year?” you ask.

   Miguel looks at his mother and says, “OK, I guess.”

   Michaela tells you that Miguel's grades have fallen from “A's” to “C's” this past quarter and she's worried that he can't think very well.

   “Maybe you'd like to come back another time and talk to me about how we can put some weight back on you so that you feel better about yourself and you're able to think better at school?” you ask.

   Michaela smiles encouragingly at her son and Miguel agrees to come see you again.

· 11.5–1 Briefly state what strengths you observe in this family.

 

· 11.5–2 What are some questions that you'd like to explore further with Michaela and Miguel?

 

· 11.5–3 Are there other individuals that you would like to interview concerning this family?

 

· 11.5–4 What is your primary diagnosis for Miguel?

 

· 11.5–5 What psychosocial and cultural factors may be impacting your diagnosis?

 

· 11.5–6 What differential diagnoses would you consider in this case?

 

Case 11.6

Client name: Sissy Stone

Age: 6

Ethnicity: Caucasian

Educational Level: Rising first grader

Intake Information

Mrs. Nash is a 45-year-old, Caucasian, single mother with a high-school son, Grant, and a college- aged daughter, Natalie. She works as a foster parent for New York Child Protective Services and has three foster children currently living in her home. About five weeks ago, during summer break, Sissy Stone was placed with Mrs. Nash and her three other foster children after Sissy's mother was checked into a drug rehabilitation center. You have been monitoring Sissy's case since she was placed in Mrs. Nash's home. You have worked with Mrs. Nash before and had good experiences with the level of care she provided your clients.

   Mrs. Nash states that Sissy is avoiding all interaction with the foster family, is crying most of the time, and is not eating well. She reports that this has been going on for the past 2 weeks. She is worried because she knows it takes foster children a while to adjust, but it is only getting worse with time. You agree to visit with Sissy at the foster home.

   When you arrive at the Nash residence, Mrs. Nash greets you at the door with a big smile. She seems relieved you have arrived. As usual, her house is clean and there are lots of children's toys and activities scattered about. You casually chat about the other foster children as well as her older children. Transitioning to Sissy's progress, Mrs. Nash comments that she has never seen a child so despondent. You ask if anything besides her mood seems out of the ordinary. Mrs. Nash hesitates, but mentions that when she does the laundry, there are excrement stains on Sissy's underwear. She says she has not mentioned anything to Sissy because it does not seem like a very big problem. “Nothing a little bleach can't fix!” she says with a laugh. “Still, it is a little unusual for a child her age.” Mrs. Nash wonders if maybe her mother just did not teach her very good personal hygiene. After meeting with Mrs. Nash for 30 minutes, you ask to meet individually with Sissy.

Initial Interview with Sissy

Sissy is lying on the couch in the living room watching TV when you go in to talk to her. She looks tired and her gaze wanders from the TV screen. Sissy looks up at you as you enter the room but does not speak. You remind Sissy of your name and tell her that you are here to see how she is doing and she passively nods. Pulling out some art supplies from your bag, you invite Sissy to color with you. She agrees silently. She picks out her crayons and starts to draw a picture.

   “What is happening in your picture?” you ask.

   “The little girl is playing outside.” Sissy responds quietly. When you ask if she would like to play outside today, she says she misses her swing and her yard. You talk about what things Sissy likes to do where she lives right now, but she does not come up with many ideas besides watching TV. Sissy seems to have a hard time focusing on the conversation and she appears tearful.

   Looking back at her picture, you wonder aloud, “How is that little girl feeling?”

   “She is sad and her tummy hurts,” Sissy says, her voice barely above a whisper.

   After talking to Sissy a little more, you tell her that you are so glad that you were able to color with her some today. She smiles weakly and goes back to absently watching TV.

   Stepping out of the room, you look up her scanned medical records on your laptop. There is no mention of Sissy ever having any kind of gastrointestinal medical problem. You ask Mrs. Nash to take Sissy to the doctor, noting that she is not eating and seems to be complaining of a stomachache.

Interview with Kindergarten Teacher

You call Sissy's previous teacher, Mrs. Lyons, who taught Sissy before she moved in with Mrs. Nash during the summer.

   Mrs. Lyons has great things to say about Sissy. She was usually a very curious, compassionate child with a fairly reserved demeanor. Music was Sissy's favorite subject, although she was generally engaged and enjoyed school. You ask what Sissy's moods were like throughout the last school year. She reports that Sissy went through two sad spells during the year in her classroom. In fact, the change was so dramatic that she called Sissy's mother to check in and see what was going on. Her mom said she thought it was just a phase and was seeing if the moods would pass. Mrs. Lyons states that Sissy's mom seemed like an overwhelmed single parent, but always came in for parent–teacher conferences. After a few weeks, Sissy's mood got better, but then a few months later it returned a second time.

   When you ask for more details about Sissy's sad spells, Mrs. Lyons says, “She always looked so tired to me, and her mom said she was sleeping much more than usual during those spells. She was less interested in activities that usually she loved, like music time. Sissy also had a much harder time paying attention to the activities. She just seemed very distant and distracted. It was very odd to me because most of my students will have a bad day, or even a bad week, but Sissy's spells went on every day for weeks.” When you ask about stomachaches, Mrs. Lyons says she does not remember that. In fact, she does not remember Sissy's appetite decreasing at all, although she notes she was not a big eater to begin with.

Phone Call with Mrs. Nash

About one week later, you get a phone call from Mrs. Nash. What started as stains in Sissy's underwear has become worse and so have Sissy's stomachaches. Sissy seemed very embarrassed about her accidents and sometimes refuses to get out of bed in the morning and made Mrs. Nash promise not to tell the other foster children what happened.

   Mrs. Nash was finally able to get Sissy into see a doctor who accepts Medicaid. The doctor said that Sissy has constipation but that she could not find any underlying medical cause. She prescribed some medications to help with the constipation but recommended that Mrs. Nash call you for further support.

   Mrs. Nash also says that Sissy is still having a hard time. She has not noticed that Sissy's mood has improved at all, and in fact she thinks it may be getting worse. She is especially worried because school will be starting in about a month and she does not know how Sissy will be able to learn anything in her current state.

   You decide to go to Mrs. Nash's home and do some further play therapy with Sissy if possible. On the day you arrive, once again, Sissy is lying on pillows in front of the TV watching cartoons.

   “Hi, Sissy, remember me?” you ask.

   Sissy nods her head, sits up and says, “You're the lady with all the art stuff. Are we going to draw today?”

   “How would you like to play with a family of dolls?” you ask.

   Sissy looks curiously at your bag. “Do you have a family in there?”

   You respond by pulling the dolls out of your bag and showing her the dolls that represent the mother, father, and two children.

   “Oh, those look like real people,” Sissy remarks. “Can I see them?”

   “Of course you can. They are sort of like real people,” you respond.

   Sissy examines the anatomically correct dolls and says, “Oh, they have all their private parts!”

   “They sure do, just like real people,” you suggest.

   Sissy gathers all the dolls around her and says, “Well, once upon a time there was a family with a mommy and daddy and brother and little girl. And the daddy goes away because he did something bad.”

   “What did he do?” you ask.

   “Well, he took something that didn't belong to him and now he's in jail,” Sissy states in a matter-of-fact tone. “And the mommy is very sad because the daddy is gone.”

   “How do you know the mommy is sad?” you interject.

   “Cause she cries a lot and then she drinks a lot of beer,” Sissy says. “The mommy says go up to your room and play!” Sissy demonstrates with the dolls. She takes the girl doll and pretends she's going to her room and slamming the door.

   “Is the little girl mad at the mommy?” you ask.

   “She doesn't like it when her mommy's boyfriends come over and she has to go to her room,” Sissy tells you in a soft voice.

   “Do the boyfriends bother the little girl?” you ask.

“No,” Sissy holds the girl doll. “They just drink beer with the mommy.”

   “Sounds like the little girl might be lonely all by herself in her room,” you query.

   Sissy plays with the girl doll and holding it in

   “I wish the boyfriends would go away and daddy would come home and everyone would be happy again,” Sissy whispers behind the girl doll's head. “And I wish mommy wouldn't drink beer because it makes her sad and then she cries.”

   “How does the little girl feel when mommy is sad?” you ask.

   “She gets sad, too.” Sissy muses. “I don't think she'll be happy until the daddy comes home.”

   “So, the little girl really misses the daddy,” you suggest.

   “She really really misses him,” Sissy says longingly. “He was the best daddy in the world.”

   After playing for a few more minutes, Sally tires of the dolls and asks you if you have coloring paper in your bag. You give her some paper and crayons and she draws a picture of her family and her father behind bars. The little girl in the picture has a downturned mouth and looks very lonely in the picture. You tell Sissy that you enjoyed playing with her and that you would come back again sometime soon. Sissy gives you a hug when you leave.

· 11.6–1 What are some of the strengths you observe in Mrs. Nash?

 

· 11.6–2 What other information would be helpful to you in better understanding Sissy?

 

· 11.6–3 What are some resources that might help this foster family?

 

· 11.6–4 What is your primary diagnosis for Sissy?

 

· 11.6–5 What are some of the cultural and psychosocial factors that impact your diagnosis?

 

· 11.6–6 What are the differential diagnoses you might consider in this case?

 

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Wildes, J. E., Emery, R. E., & Simons, A. D. (2001). The roles of ethnicity and culture in the development of eating disturbance and body dissatisfaction: A meta-analytic review. Clinical Psychology Review, 21(4), 521–551.

Woodrow Wilson International Center for Scholars. (2000). Eating disorders in children. The Wilson Quarterly, 24(3), 10.

12 Sleep-Wake Disorders

Disorders

This section in the DSM-5 ( APA, 2013 ) contains diagnoses related to disturbances in the sleep process that cause clinically significant distress and/or psychosocial impairment. There have been major breakthroughs in the epidemiology and neurobiology of sleep, which are reflected in the diagnostic criteria contained within this chapter. Sleep-wake disorders are no longer diagnosed based on their causal agents, which has resulted in the removal of both “sleep disorders related to another mental disorder” and “sleep disorder related to a general medical condition” from the DSM-5 ( APA, 2013 ). Disorders have been arranged to help guide mental health and medical clinicians in the differentiation of sleep-wake conditions, which can be challenging due to overlap with coexisting medical (e.g., congestive heart failure) and/or mental disorders (e.g., anxiety, depression); cognizant of the fact that frequently sleep disorders merit independent diagnosis. Often when sleep-related disorders are coupled with comorbid disorders the impairment in functioning is intensified. Chronic, sleep disturbances (both insomnia and hypersomnolence) are known risk factors for later development of psychiatric illness and substance use disorders. Additionally, within the diagnostic criteria (e.g., diagnostic markers) for each disorder are guidelines for when referral to a sleep specialist is appropriate (e.g., narcolepsy, breathing-related sleep disorders, non-REM sleep arousal disorders). The resulting changes were intended to help clarify criteria regarding referrals to sleep specialists, and to provide descriptions of relevant comorbid medical and psychiatric conditions. Additionally, dimensional features (e.g., course and symptom severity), developmental criteria, and subtypes were provided for each disorder when appropriate in effort to support treatment planning ( APA, 2013 ). This workbook seeks to provide clinicians with a general overview of the sleep-wake disorders and is not intended to be a detailed breakdown of the diagnostic criteria, scientific definitions, and biological validators, or a replacement of this manual. For more detailed information refer to the DSM-5 ( APA, 2013 ).

   The first sleep-wake diagnosis, Insomnia Disorder replaces primary insomnia and reflects the elimination of an earlier delineation (e.g., primary versus secondary insomnia) in keeping with classification changes in regards to causation. Basically, insomnia is characterized by difficulties in the quality or quantity of sleep in terms of problems initiating, maintaining, and/or awakening without ability to return to sleep (in children without caregiver intervention). For diagnosis, the insomnia must occur for at least 3 nights/week and present for a period of at least 3 months (even with ample sleep opportunities) and cause significant distress and/or psychosocial impairment. When insomnia occurs with a concurrent medical or mental condition, an independent diagnosis is only given when it causes clinically significant impairment. Also, the insomnia cannot be better explained by another sleep-wake disorder or due to the physiological effects of a substance or co-occurring medical/mental disorder. Specifiers include with non-sleep disorder mental comorbidity, with medical comorbidity, and with other sleep disorder, whereas course specifiers include episodic (symptoms last for at least 1 month but less than 3 months), persistent (symptoms last 3 months or longer), and recurrent (more than two episodes within a year). Differential criteria and coexisting medical (e.g., diabetes, COPD) and mental disorders (e.g., bipolar, depression, anxiety disorders) are included. For details see DSM-5 ( APA, 2013 ).

   Insomnia is a common problem with population estimates at over one-third of adults reporting symptoms and, as many as 6% to 10% of adults meet criteria for Insomnia Disorder. Insomnia has the highest prevalence rate of all sleep disorders and slightly more frequent among females with a gender ratio of 1:44 to 1. Insomnia is the most common coexisting condition with another medical or mental disorder; more strikingly, 40% to 50% of individuals with insomnia also have a co-occurring mental disorder ( APA, 2013 ).

   Hypersomnolence Disorder is a new category characterized by excessive sleep that occurs no less than 3 times per week for 3 months or longer, despite a lengthy sleep period (at least 7 hours) and replaces primary hypersomnia (in line with other classifications changes due to causation). Moreover, symptoms significantly interfere with psychosocial functioning and/or cause clinically significant distress. The hypersomnolence must include at least one symptom of either recurrent periods of sleep, and/or prolonged sleep, and/or sleep inertia after awakening (e.g., grogginess). Hypersomnolence cannot occur solely during the course of another sleep disorder (e.g., narcolepsy) or be better explained by coexisting medical and/or mental disorders (all three are specifiers), and excludes the physiological effects of substance use. Course (e.g., acute, subacute, persistent) and severity (e.g., mild, moderate and severe) are also coded with specifiers. For details consult the DSM-5 ( APA, 2013 ).

   Narcolepsy has been separated from the other conditions of hypersomnolence and classified into five subtypes based on clinical research and laboratory findings. This disorder is characterized by irresistible episodes of the need to sleep, progressing into sleep, which occurs at least 3 times per week over a 3-month period. In addition, at least one of the following symptoms must be present for diagnosis: episodes of cataplexy (brief episode of loss of muscle power); hypocretin deficiency; and/or sleep testing showing intrusions of REM sleep latency (for details see  APA, 2013 , p. 373). The five subtypes (e.g., with cataplexy and hypocretin deficiency) are indicated via specifiers as is symptom severity, which range from mild (e.g., infrequent cataplexy and naps with less disturbed night sleep) to severe (e.g., drug-resistant cataplexy with daily episodes, constant sleeplessness, and disturbed nighttime sleep). In children, narcolepsy may present with atypical cataplexy (e.g., affecting face only) and motor disturbances can range from hypotonia to overactivity. Other associated features that individuals may experience include semiautomatic behaviors without memory (e.g., nocturnal eating/smoking), hallucinations in the transitions between being awake and sleeping, and sleep paralysis. Further details and examples can be found in the DSM-5 ( APA, 2013 ).

   Prevalence rates of hypersomnolence, both symptoms and the disorder, are less known for the general population, but estimates for sleep clinic populations are from 5% to 10% of treatment-seeking individuals. Narcolepsy-cataplexy is estimated at .02–04% of the general population worldwide. Gender ratios for both disorders are generally equal ( APA, 2013 ).

   The breathing-related sleep disorders in the DSM-5 ( APA, 2013 ) are changing to reflect an increasing understanding of the biology and nature of sleep and to help further guide treatment planning. This category now encompasses three distinct disorders including: Obstructive Sleep Apnea Hypopnea; Central Sleep Apnea; and, Sleep-Related Hypoventilation. For diagnosis, all three require biological validators (usually through polysomnography) and referral to a sleep specialist ( APA, 2013 ). Research has shown that breathing-related disorders with comorbid mental disorders (e.g., major depressive disorder, schizophrenia) can exacerbate psychiatric symptoms ( Reynolds & O'Hara, 2013 ).

   Obstructive Sleep Apnea Hypopnea is the most prevalent breathing-related sleep disorder and is characterized by persistent occurrence of upper airway obstructed breathing (both apneas and hypopnea). For diagnosis, at least five apneas/hypopneas per hour of sleep must occur with either/or both of the following symptoms: nocturnal breathing disruptions (e.g., snoring, gasping, pausing); and/or daytime sleepiness, exhaustion and unrestful sleep even with adequate time for sleep; and, not understood to be the result of another sleep disorder/mental disorder or medical condition. Symptom severity (from mild to severe) is indicated through specifiers tied to the number of apneas/hypopneas per hour. Prevalence of this disorder is reported at 1–2% of children (usually due to enlarged tonsils); from 2% to 15% of middle-aged adults (highest for males); and, highest rates found in older age (over 20%) with gender differences evening out. Primary risk factors include obesity and male gender ( APA, 2013 ).

   Central Sleep Apnea is a less common breathing-related disorder marked by at minimum five apneas/hypopneas per hour of sleep; and, not due to the presence of another sleep-related disorder. The three subtypes of this disorder are based on respiratory effort/patterns and include idiopathic (e.g., periodic breathing without obstruction), Cheyne-Stokes (e.g., periodic breathing tied to heart and renal failure and strokes), and Central Sleep Apnea comorbid with opioid use (e.g., breathing pattern due to effect of opioids use). Prevalence is unknown for idiopathic but is skewed toward males and increasing with age in Cheyne-Stokes subtype. When tied to chronic opioid use, the prevalence rate is estimated at 30% ( APA, 2013 ).

   The next category, Sleep-Related Hypoventilation, is diagnosed only through polysomnography, is characterized by decreased respiration due to a rise in carbon dioxide blood levels, and is associated with sleep-related symptoms such as sleepiness and insomnia. The prevalence of these disorders is currently unknown but thought to be rare, but more common with comorbid medical conditions (e.g., COPD, neuromuscular disorders) or obesity. For details on diagnostic criteria and specifiers refer to the DSM-5 ( APA, 2013 , pp. 387–390).

   Circadian Rhythm Sleep Disorders are diagnosed when there is a persistent or recurrent pattern of sleep disruption due to disruptions in the normal sleepwake schedule. The subtypes include delayed sleep phase type, advanced sleep phase type, irregular sleep-wake type, non-24-hour sleep-wake type, and shiftwork type (jet lag type has been removed). For diagnosis, the disturbed sleep symptoms must include excessive sleepiness and/or insomnia, as well as cause clinically significant impairment ( APA, 2013 ). Typical problems associated with these disorders are difficulty falling, maintaining, and getting back to sleep, as well as frequent waking and feeling unrested after sleep. The origin of each sleep disruption is made clearer by the specifiers used. For example, in delayed sleep phase type, the individual is unable to fall asleep or awaken at a desired/or what is considered normal time (with the delay lasting usually more than two hours). Shift work type describes disruptions that occur because one works the night shift (and is consequently trying to sleep during the day) or changes shift assignments often. Coding is based on subtype, with the addition of “unspecified type.” The course of each disorder must be specified (e.g., episodic, persistent, recurrent) and other specifiers include notation for family history and for overlap with other sleep-wake disorders ( APA, 2013 ). For details on prevalence, risk factors, differential diagnosis, and comorbidity for each disorder consult the DSM-5 ( APA, 2013 ).

   The other grouping of disorders covered in this chapter is the Parasomnias, in which some disruptive event occurs during specific sleep periods and/or transitions. More specifically, these conditions refer to instances in which behaviors or physiological processes are activated inappropriately while the individual is asleep ( APA, 2013 ). The three disorders included in this grouping are Non-Rapid Eye Movement (NREM) Sleep Arousal Disorder, Nightmare Disorder, and Rapid Eye Movement (REM) Sleep Behavior Disorder. For all three NREM sleep arousal disorders diagnostic criteria require that the sleep disturbance must cause clinically significant impairment and distress, cannot be attributed to the effects of a substance, and the diagnosis is not better explained by a comorbid mental and/or medical disorder ( APA, 2013 ).

   In NREM, repeating episodes of semi-arousal from sleep occur early in the sleep cycle accompanied by either sleepwalking (e.g., rising from bed performing various motor activities during sleep) or sleep terrors (e.g., sudden terror arousal from sleep with fear and signs of automatic arousal). Both subtypes need to be indicated and, in the case of sleepwalking, further demarcation for sleep-related eating and/or sexual behavior needs to be ascertained. There is no memory of the episode and little to no recall of dream imagery ( APA, 2013 ).

   In Nightmare Disorder the individual experiences repeated awakenings with detailed recall of frightening dreams. Upon awakening, he or she rapidly becomes oriented (unlike sleepwalking or sleep terrors). These episodes generally occur during the second half of the sleep period. Clinicians must specify severity (from mild to severe), duration (acute, subacute, persistent), comorbidity (non-sleep disorder, other medical condition, other sleep disorder), and course onset ( APA, 2013 ).

   REM Sleep Behavior Disorder is now an independent diagnosis in the DSM-5 ( APA, 2013 ). Core features of this disorder include the acting out of vivid dreams through verbal expression and prominent movement during REM sleep. Once awakened the individual appears alert and oriented. Some of the more technical core features include polysomnographic confirmation of REM sleep with loss of atonia and/or a history suggestive of REM Sleep Behavior Disorder and an established neurodegenerative disease (e.g., Parkinson's). For details consult the DSM-5 ( APA, 2013 ).

   The prevalence of NREM Sleep Arousal Disorders are more common in children, with the exception of REM sleep behavior disorder, which is more prevalent in males aged 50 and over, and sleep terror disorder, which occurs equally among children and adults. Sleepwalking Disorder usually begins in childhood and ends in adolescence. Initial onset of sleepwalking in adulthood is unusual. Sleepwalking is more common in females during childhood but reverses and becomes more common in males with adulthood. Sleepwalking related sexual behavior is more frequent in male adults, whereas females report more sleep-related eating. A family history for sleepwalking and sleep terrors increases the risk of both disorders. Nightmare Disorder usually begins in children between the ages of 3 and 6 and causes significant disruptions for both the children and their parents. Although most children simply outgrow this disorder, it can persist into adulthood, especially for females. REM Sleep Behavior Disorder has a strong link to neurodegenerative disorders and warrants neurological monitoring. Also, if symptoms occur in young females further screening for Narcolepsy or Substance/Medication-Induced REM Sleep Behavior Disorder is suggested ( APA, 2013 ).

   Restless Legs Syndrome (RLS) is now a distinct diagnostic category in the DSM-5 ( APA, 2013 ), which is supported by growing neurological data and research. Diagnosis is made primarily based on patient self-report and history. Core features include the urge to move legs along with irritating and uncomfortable sensations, which occur at least 3 times per week for a minimum of 3 months. For diagnosis, symptoms must begin or deteriorate due to lack of activity, are somewhat to fully reduced by movement, nocturnal worsening or only arise at nighttime regardless of activity level. Also, symptoms are accompanied by clinically significant distress or impairment, are not due to some other medical/mental disorder or behavioral condition, and/or substance/medication-induced ( APA, 2013 ).

   Risk factors for Restless Legs Syndrome include female gender (1.5% to 2% times more likely than in males), advancing age, genetics, and family history. The prevalence of this disorder ranges from 2% to 7.2% depending on criteria employed ( APA, 2013 ).

   Substance/Medication-Induced Sleep Disorder as can be implied, are drug and alcohol induced sleep disorders. However, the prominence of sleep disturbance is significant to result in independent diagnosis. There are four subtypes based on symptoms including insomnia type, daytime sleepiness type, parasomnia type, and mixed type, with the first two types most common. Also, onset must be specified (e.g., during intoxication, during withdrawal) and verified through patient history, physical exam, or laboratory findings that a susbstance (and not preexisting sleep/mental/medical disorder is the cause of the condition. For all diagnostic criteria as well as prevalence, gender, comorbidity consult the DSM-5 ( APA, 2013 ).

   The other sleep-wake disorders that can be found in this chapter include Other Specified Insomnia Disorder, Unspecified Insomnia Disorder, Other Specified Hypersomnolence Disorder, Unspecified Hypersomnolence Disorder, Other Specified Sleep-Wake Disorder, and Unspecified Sleep-Wake Disorder. For a full description of these disorders along with diagnostic criteria and important clinical implications refer to the DSM-5 ( APA, 2013 ).

Assessment

Assessment of sleep disorders has become a technologically advanced medical procedure in recent years. Clinics designed to diagnose the various sleep disorders are usually found as part of general hospitals, although some freestanding clinics also exist.

   The procedures performed at these facilities are called polysomnography, or more simply, sleep studies. In the most common procedure, the client usually checks into the facility around 7:30 or 8:00 P.M. and leaves whenever he or she awakes in the morning. Typically, before going to bed, the client fills out instruments developed by the clinic to cover history about his or her concerns. Then, the client is taken to a “bedroom” equipped with observational devices and is fitted with several electrodes. The client is then monitored throughout the night, resulting in a complete set of information about breathing patterns and efforts, heart rate, oxygen saturation, brain activity, and muscle activity. From these data, a physician can diagnose sleep disorders and suggest appropriate treatments.

Less common sleep studies usually involve spending a day at a sleep clinic, where the frequency and length of daytime sleepiness is measured. There has been a proliferation of sleep centers, and each seems to have developed questionnaires for history and symptom description. Typically, nonmedical clinicians do not administer self-report sleep instruments because the data generated by sleep studies are much more helpful in diagnosing and formulating treatment.

   In terms of diagnostic instruments useful for determining the quality and pattern of a sleep disorder, the preferred screening measure is the Pittsburgh Sleep Quality Index (PSQI,  Buysse, Reynolds, Monk, Berman, & Kupfer, 1989 ). This brief, 24-item self-report questionnaire measures sleep quality along 7 domains (e.g., sleep quality, sleep disturbances) over a month period and differentiates “poor” from “good” sleepers ( Buysse et al., 1989 ). For further details on use, validity, and reliability consult:  Buysse et al. (1989)  in the references.

Social Support Systems

Most people have had the experience of temporarily disrupted sleep at one time and consequently can well imagine the potential impact of long-standing sleep disorders on the individual. Excessive sleepiness resulting from either having insomnia or caring for someone with a parasomnia can result in impaired functioning in school or at work. Although suffering from some of the sleep-wake disorders in this chapter might have little potential for disrupting relationships, others can prompt separation in sleeping arrangements between intimate partners. Particularly if other strains are present in the relationship, this separation can have serious consequences. Caring for someone with a parasomnia can be frightening and, over time, burdensome.

   With the recent increase in medical interest in this area, there has been a corresponding increase in support services and information. The following list indicates some resources available on the Internet.

·   www.nhlbi.nih.gov : The National Institutes of Health National Center on Sleep Disorders Research (NCSDR) provides information on sleep disorders for patients and the public as well as research, training, and coordination of the Federal Government's efforts on sleep disorders.

www.sleepfoundation.org : The National Sleep Foundation is a nonprofit organization, which provides comprehensive sleep education, awareness, and advocacy.

www.sleepapnea.org : The American Sleep Apnea Association is a nonprofit organization dedicated to providing education, awareness, and mutual support groups of this common sleep disorder.

www.narcolepsynetwork.org : The Narcolepsy Network is a national nonprofit patient support organization that seeks to educate, advocate, and support individuals with narcolepsy and their families.

www.aasmnet.org : American Academy of Sleep Medicine (AASM) is a professional medical society that provides professional and public education on sleep disorders and treatments on their website.

Case 12.1

Identifying Information

Client Names: John and Samantha Wildeman

Ages: Samantha, 35 years old; John, 40 years old

Ethnicity: Caucasian

Marital Status: Married

Children: One child from John's first marriage

Presenting Problem

John and Samantha Wildeman contacted the Family Counseling Agency for marital counseling. John is a 40-year-old, well-muscled individual who works as a sales distributor for a well-known frozen-pizza company. His job involves calling on grocery and convenience stores throughout the region and convincing them to buy his line of frozen pizzas. He is the sole distributor in a five-county area. Samantha is a slender, 35-year-old woman who teaches math and science at the local high school. John has one son, Robert, from his first marriage. Robert is 20 years old and away at college. He comes home periodically but has an apartment of his own.

   John and Samantha have been married for 15 years and are seeking help due to increasing stress in their marriage. They both feel that they are having difficulty communicating effectively with each other, and Samantha feels that John's behavior and personality have changed dramatically over the past year. She states that she feels John is depressed, although he denies feeling down. Samantha explains that John works on his own schedule, and there have been many days over the past several months when he just hasn't bothered to work. She says that John is usually a highly motivated selfstarter, and this behavior is very unusual for him.

   John states that he has been feeling unusually tired and may be getting bored with his job. Several times, he has been on the verge of falling asleep in the middle of an important monthly business meeting with his regional director. His regular physical exam indicated no physical problems, with the exception of John's recent weight gain of 25 pounds. It appears that the couple's marital problems are focused on changes in John's behavior and personality. John finds no fault with Samantha except that she doesn't seem to understand that he has been under a lot of pressure with his job and that he may just need some time away from work.

   You have seen John and Samantha on four occasions for couples' counseling. After the fourth session, John calls and asks to see you for an individual session. You explain to him that you can see him if he wants to come and talk about his personal issues, but he should know beforehand that he shouldn't disclose anything he doesn't want you to share with Samantha since you are seeing them as a couple. John says, “Oh, it's nothing secret. I just wanted to talk to you about some individual problems I've been experiencing lately.”

· 12.1–1 What underlying issues do you suspect are affecting John and Samantha? What do you expect John to disclose?

 

Individual Session with John

John begins the session by stating that he feels he could use some individual help with his feelings of exhaustion and malaise. He states that he has always been “a very active” sleeper, but that lately, he has been waking up several times a night with a tight feeling in his chest. He says that his mouth is so dry that he drinks several glasses of water during the night. Upon awakening in the morning, he often feels more tired than when he went to bed. This problem has gotten worse over the past year, and he feels it's affecting his marriage and his job. He goes to work tired and has difficulty staying awake driving from one location to another. His job involves a great deal of driving, so this problem has been of major concern to him because he's afraid of falling asleep at the wheel.

   You ask John whether this problem has developed suddenly or gradually. He tells you that Samantha used to get irritated because he was so active at night that he'd wake her up. Lately, however, she has complained of his snoring so loudly that it prevents her from being able to get to sleep. There have been many nights in the past several months when Samantha has taken a pillow and blanket and slept on the living room couch due to his snoring and restlessness at night. John feels that this has definitely created more friction and distance between them.

   Due to his problems sleeping, John often has difficulty concentrating on his job during the day and feels tired and distracted. “I'm so tired by the time I get home at night, I'm just ready for an argument. I really don't think that Samantha is to blame for the problems we've been having in our marriage. I just can't cope with the pressures during the day, and I take it out on her when I get home at night. I think she's right when she says I'm not the same happy-go-lucky guy I used to be. I'm actually pretty miserable to be around right now. I am much more pessimistic and depressed than I've ever felt in my life. I can't really pinpoint what the problem is, but I think it has something to do with how poorly I've been sleeping at night.”

   “Did you mention any of these symptoms to your doctor when you went to see him for a physical?” you inquire of John.

   “I did mention that I was feeling tired, but I also said I had been working long hours, and I think the doctor just dismissed it as a case of work overload,” John tells you.

   “And he gave you a clean bill of health?” you ask.

   “Well, almost,” John replies. “He said that my blood pressure was high, but he thought if I'd just lose some of this weight I've put on, it would improve my blood pressure. I guess that's what happens when you turn 40 and sell pizza for a living,” John responds with a hearty laugh.

   “It sounds as if you might have a specific kind of sleeping problem,” you suggest. “Would you be willing to go to the hospital's Sleep Disorders Clinic and have them evaluate the problem you've described? I can call them and make a referral.”

   “I'd do just about anything if I could get a good night's sleep,” says John. “It's been a long time since I've felt like I was alive and awake when I got up in the morning.”

   “Good, I'll develop a preliminary report and send it over to the doctors at the Sleep Clinic. I will need you to sign a consent form allowing me to release information to them. After you've been for an assessment, we'll get together and see where we go from there.”

   “Sounds like progress to me,” says John. “I certainly appreciate you taking me seriously today.”

· 12.1–2 What would be your preliminary diagnosis for John?

 

· 12.1–3 What would you recommend be communicated to Samantha at this point? How should this information be communicated to her?

 

Case 12.2

Identifying Information

Client Name: Katherine Carmichael

Age: 42 years old

Ethnicity: Caucasian

Marital Status: Divorced

Children: Two adolescent children

Intake Information

The intake worker reports that Katherine Carmichael called the Family Support Agency to make an appointment with a counselor. She said she hadn't been sleeping well for several months and thought it might help to talk to a counselor. She gave no further information about the cause of her sleep problems. Ms. Carmichael's schedule was full for the next 3 weeks, so an appointment was made a month in advance. The intake worker will call and remind her of the appointment 1 week prior to the time.

Initial Interview with Katherine

Katherine is an attractive, well-dressed woman who is seated in the waiting room reviewing her schedule book when you meet her. She immediately gets up, shakes your hand, and walks with you to your office. She is dressed in a light gray business suit with matching shoes and handbag. She appears to have come directly from work for this appointment.

   After explaining your role as a counselor and the issues of confidentiality and informed consent, you begin by asking Katherine why she decided to make an appointment. Katherine brushes her hair back from her face and tells you she hasn't been sleeping well for about the past 4 months, and nothing she tries to resolve the problem seems to work.

   “I own a real estate company here in town and have 45 agents working for me. I also sell houses myself. Recently, I've started a corporate real estate division, and we've been extremely busy getting that started as well. As you probably know, people in real estate work all hours of the day and night and weekends, and, well, business is just always on my mind. There are so many little pieces of a transaction that have to be taken care of when you sell a house, and I'm always thinking about my ‘to do’ list, which never seems to get any shorter.”

   “It sounds like you work a lot of hours,” you suggest.

   “I probably average 70 hours a week, especially in the past year or two. People have been buying houses like crazy,” Katherine states. “I rarely get through a dinner without the phone ringing. Not that I don't enjoy it. I love my work and have been very successful at it, but there's very little leisure time available when you own your own business. And then I have my children to think about, too.”

   “And how old are your children?” you ask.

   “Tony is 15 and plays soccer after school, and Theresa is 13 and she's got ballet and art classes every day after school. I try to work it out so I can attend some of Tony's games and take Theresa to her ballet classes, but it's hectic at times,” Katherine explains.

   “Sounds like you're very busy,” you suggest.

   “Extremely busy. I don't have time to breathe most of the time. You would think I'd sleep like a log, but I just haven't been able to,” Katherine replies. “It should be better next year when Tony can drive. That will be a big help to me.”

   “I'm sure that will be,” you reply. “How are you juggling all of this work and children as a single mother?”

   “Well, my ex-husband helps some with getting the kids to their activities when he's in town. But he's gone a lot on business, so he's not always around. We still have a friendly relationship, but we communicate mostly through answering machines,” Katherine states.

   “Besides being extremely busy with your job and the children, are there other things that have been bothering you lately?” you ask.

   “No, not really. I just can't seem to turn my mind off until late at night. When I finally get to sleep, I sleep for a few hours and then I'm wide awake again at 3:30 or 4:00 A.M. And I'm afraid if I go back to sleep, I won't hear the alarm and will be late getting the kids to school.”

   “So you're having a difficult time getting to sleep,” you note. “About what time do you get to sleep?”

   “Oh, it's about 11:30 or midnight before I get to sleep, so I'm existing on 3 or 4 hours of sleep every night, and I'm just exhausted if you want to know the truth,” Katherine responds.

   “Are you taking any medications?” you ask.

   “Well, I tried an over-the-counter drug to help me get to sleep, but it didn't really help, so I quit taking it,” Katherine replies.

   “Anything else, even if it's not for sleep?” you ask.

   “No, I don't take anything prescribed,” Katherine responds.

   “What about alcoholic beverages?” you ask. “How often do you consume alcohol?”

   “Only occasionally, when I go out for dinner or on special occasions,” Katherine states. “Nothing on a routine basis. For my children's sake, I don't keep alcohol in the house.”

   “How has your mood been lately?” you inquire. “Have you noticed any changes in your mood?”

   “I'm probably a bit more grouchy because of lack of sleep and, in general, just tired all the time,” Katherine explains.

   “Have you felt anxious or depressed lately?” you ask. You wonder if there have been any changes in Katherine's emotional state recently.

   “No, I wouldn't say I'm anxious or depressed, but I do worry a lot about the business. I'm just responsible for so much that it's overwhelming at times.”

   “Okay, so you really feel that the primary difficulty you've been experiencing lately has been related to sleep?” you inquire.

   “Yes, that's the only thing that's really bothering me right now. I think if I could sleep better, I'd feel more energized and able to handle all the demands of work and home,” Katherine tells you.

   “That sounds like something we can work on together. Would you be willing to make time to come in and see me once a week for the next few weeks?” you ask.

   “Yes, I'll make a point to clear out a time to come in. I really want to get back to sleeping better,” Katherine explains.

· 12.2–1 What strengths did you notice in Katherine and/or her situation?

 

· 12.2–2 List the stressors she is currently experiencing.

 

· 12.2–3 What would be your preliminary diagnosis?

 

· 12.2–4 List by V codes any psychosocial or cultural factors that might impact this diagnosis.

 

· 12.2–5 Are there additional diagnoses you would like to consider?

 

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: Author.

Buysse, D., Reynolds, C., Monk, T., Berman, S., & Kupfer, D. (1989). The Pittsburgh Sleep Quality Index: A new instrument for psychiatric practice and research. Psychiatry Research, 28(2), 193–213.

Reynolds, C., & O'Hara, R. (2013). DSM-5 sleep-wake disorders classification: Overview for use in clinical practice. The American Journal of Psychiatry, 170(10), 1099–1101. doi:10.1176/appi.ajp.2013.13010058

17 Neurocognitive Disorders

Disorders

The mental disorders covered in these two sections of the DSM-5 ( APA, 2013 ) share etiology related to physiological processes. For most of these disorders, this physiological causal issue is a general medical condition that is acquired rather than being a developmental disorder. Furthermore, these disorders have been heavily researched. After decades of intensive study, scientists have uncovered potential biological markers (not yet scientifically verified) that may have great clinical utility as more is learned about how the brain functions. In addition, there are also some specific diagnoses that are related to the use of one or more substances or exposure to a toxic agent. The DSM-5 has also clearly indicated that neurocognitive disorders (NCDs) can be diagnosed in younger adults as well as older populations. For example, military veterans who experience traumatic brain injuries tend to be young men under 50 years old. On the other hand, Alzheimer's disease is more prevalent among older adults over 65 years old.

   The hallmark of Delirium is a disturbance in consciousness (i.e., awareness of one's environment and/or the capacity to focus and direct one's attention). Other disturbances in cognitive functioning (e.g., language disturbance, disorientation, memory deficits) may be present as well. This condition develops over a relatively short period of time, and the intensity of symptoms fluctuates in the course of a day. Some of the most common risk factors for Delirium include use of a general anesthetic or multiple medications, a history of drug or alcohol abuse, sensory loss, social isolation, unfamiliar environments, sleep deprivation, central nervous system disorders, metabolic disorders, and cardiopulmonary disorders. The specific Delirium diagnoses are determined by the underlying cause (i.e., a medical condition, with or without substance use, or an unknown etiology) ( APA, 2013 ). The coding for each of these diagnoses is based on the specific type of drug use involved, medical condition or multiple etiologies ( APA, 2013 ).

   In contrast, the prominent symptoms for Mild and Major NCDs include cognitive disturbances related to language deficits, executive functioning, perceptual functioning, social cognition, learning, and memory. Most NCDs develop slowly and display a steadily deteriorating course. The exceptions to this pattern include stroke and traumatic brain injury, in which symptoms appear rapidly after the damaging event. Symptoms are directly related to the portion of the brain that is being affected. The distinction between Mild and Major NCD is in the degree of cognitive decline that is both observed and assessed by objective testing. Mild NCDs involve a modest decline in cognitive functioning from previous levels of performance, whereas Major NCDs involve significant cognitive decline. For example, in Mild or Major NCD due to Alzheimer's Disease, impairment is focused in the parietal and temporal portions of the brain, which are central to memory functions. The “mild” form of this disorder allows the practitioner to diagnose the disorder in its earliest stages, which can lead to beneficial treatments that may delay the onset of more severe symptoms. Some of the most common medical conditions related to NCDs are Alzheimer's disease, Pick's disease, HIV disease, Parkinson's disease, Huntington's disease, and brain traumas (including strokes). As it does for Delirium, the DSM-5 ( APA, 2013 ) includes a series of neurocognitive diagnoses related to the underlying causation: a Specified General Medical Condition, Substance-Induced Neurocognitive Disorder, Traumatic Brain Injury, Neurocognitive Disorder due to Multiple Etiologies, or Unspecified Neurocognitive Disorder (when the etiological basis is not known).

Assessment

When a practitioner conducts assessments related to these disorders, a crucial component is a thorough medical exam by a specialist. Often, prognosis for these clients is determined by whether or not the underlying medical situation can be remedied. For nonmedical practitioners, specifically psychologists licensed to administer neurocognitive batteries of tests, the primary focus of assessment with these mental disorders is on cognitive functioning. Because deficits are, by definition, present, most standard assessment tools utilize ratings by clinical professionals rather than client self-reports.

   The Memorial Delirium Assessment Scale (MDAS;  Breitbart, Rosefeld, Roth, Smith, et al., 1997 ) is the most commonly used rating scale for Delirium. The MDAS contains 10 items for which the clinician rates the severity of dysfunction, ranging from “none” to “severe.” In addition to being a useful instrument, this scale gives a fairly clear understanding of the range of potential symptoms that can be classified as Delirium. Initial psychometric work has shown evidence of strong interrater reliability and concurrent validity with a variety of more burdensome measures (see  Grover & Kate, 2012  for a thorough overview of Delirium measures). The MDAS has been used as a monitoring tool as well.

   Although a variety of ratings scales related to NCDs are available, the Clinical Dementia Rating scale (CDR;  Hughes, Berg, Danziger, Coben, & Martin, 1982 ) is often used. The original CDR contains 6 areas for ratings and, similar to the MDAS, is instructive in clearly delineating the range of problems that may be present in clients with Dementia. The CDR has been updated ( O'Bryant, Lacritz, Hall, Waring, et al., 2010 ) to include more emphasis on judgment and problem solving as they relate to financial management.

   Another approach, the Mini-Mental Status Exam (MMSE;  Folstein, Folstein, & McHugh, 1975 ) has long been the primary monitoring tool used with people with cognitive problems. This scale specifies 11 tasks that range across various areas of cognitive functioning. For each, a scoring guide is provided and a cutoff score of 23 out of 30 possible points is considered diagnostically significant. Folstein ( 1998 ) has recently reviewed the use, limitations, and related ratings of the MMSE.

   The WHODAS 2.0 (World Health Organization Disability Assessment Schedule 2.0) found in the DSM-5 can be used to measure the degree of functional disability in 6 domains of daily living. The instrument measures communication, mobility, self-care, interpersonal relationships, home/school/work activities, and participation in society ( APA, 2013 ).

   These instruments are screening tools that would provide the practitioner with some measure of the degree of disability experienced by the individual as well as the need for further testing. If the practitioner assessed the client to have some form of neurocognitive dysfunction, the client should be referred to a qualified psychologist for further, in-depth testing.

Cultural Considerations

The DSM-5 has clearly indicated that NCDs can affect young and old alike. However, the vast majority of persons with Major NCDs such as Alzheimer's disease, and other chronic neurological problems (e.g., Parkinson's disease) are the elderly of our society. Regardless of age, most individuals with these disorders are in need of assistance and considerable caregiving. Research indicates that 15 million people in America provide informal, unpaid care that older persons and individuals with chronic disabilities need ( http://caregiver.org/node/90 ). Currently, approximately 70 million people in the United States who have cognitive impairments live at home ( Alzheimer's Association, 2009 ). A spouse or adult child of the affected person is most likely to take the role of primary caregiver.

   Informal caregiving can take many forms and ranges from an adult child dropping by once a week to check on a parent, to an older parent moving in with his or her adult children or a spouse caring for his or her partner 24 hours a day. Caring for a person with a cognitive disorder can be an exhausting activity, and there is ample evidence to suggest that cultural variations exist among different ethnic groups within our society in terms of the norms, values, and beliefs associated with caring for family members. Practitioners, who often provide additional support to families coping with the stress of caring for an individual with a cognitive disorder, should be aware of these cultural variations.

   Informal caregiving activities are ubiquitous among all ethnic groups within our society. Although Caucasian families utilize formal support mechanisms more frequently than minority groups do, all families experience stresses and strains due to the necessity of caregiving. Traditionally, African-American, Asian/ Pacific Islander, and Hispanic families have held strong beliefs about maintaining caregiving responsibilities within the family unit. Therefore, ethnic minority families are often seen as underutilizing resources available to them in the community.

   Research suggests that psychoeducational group support can benefit caregivers from multi-ethnic backgrounds. For example, one study of Korean caregivers participating in a psychoeducational group based on the evidence-based REACH model showed that Korean American caregivers could benefit from education on NCDs, social support from other Korean American caregivers, the need for information to be delivered in Korean and the heterogeneity of needs related to the stages of the disease and the needs of the care receiver and caregiver ( Lee & Yim, 2012 ). Another study suggests that African American caregivers who experience caregiver burden and depression could benefit from a cognitive behavioral therapy telephone group as well as a face to face CBT group in order to increase social support, and reduce symptoms of burden and depression ( Glueckauf, Davis, Willis, Sharma, et al., 2012 ). Likewise, Chinese American families, a culturally diverse group within itself, hold strong beliefs in the family caring for each other, particularly in respect to the older generation. One study indicated that Chinese American caregivers had a strong desire to become educated about NCDs despite their lack of education pertaining to the diseases ( Ho & Woo, 2013 ).

   Hispanic families who have immigrated to the United States have also maintained a traditional philosophy about family roles. The younger generation venerates the older generation and is expected to care for them when they become ill. Furthermore, unlike some of the Asian individuals who seek help if family members are not available, Hispanic older persons may “suffer in silence” rather than ask for outside assistance ( Mangum, Garcia, Kosberg, Mullins, et al., 1994 ). However, one study examining the development of a psychoeducational support group for Alzheimer's caregivers in the Hispanic population indicated that extensive personal contact with professionals who were culturally competent was conducive to good participation in culturally sensitive support groups. Additionally, Hispanic caregivers benefited from the knowledge gained from the formal presentations and the informal information gained from other group members was also very useful ( Marano & Bravo, 2002 ).

   Therefore, it is important for practitioners working with cognitive-disordered clients and their families to be aware of culturally diverse philosophies of caregiving. Although all families may require support in coping with the stress of caregiving, the type and degree of support may vary across cultures. Being able to establish a culturally sensitive relationship with the client and family will more likely lead to a successful long-term outcome in caring for the individual with the disability.

Social Support Systems

Because most of the disorders in these sections of the DSM involve rather substantial problems in terms of cognitive functioning, it should be evident that clients with these disorders require assistance to maintain functioning. This dependency may become so pronounced that institutionalization becomes necessary.

   Both the provision of assistance and the decision making about appropriate placement and care can cause substantial amounts of stress. Along with these demands, caregivers are typically grieving various losses associated with the client's deterioration. This accumulated physical, emotional, financial, and social stress is commonly referred to as caregiver burden. Beeson, Horton-Deutsch, Farran, and Neundorfer ( 2000 ) found a significant relationship between loneliness, depression, and relational deprivation among Alzheimer's caregivers. Female caregivers experienced the greatest amount of loneliness and depression, with wives experiencing more loneliness than daughters. Husbands also experienced loneliness but at lower levels than those of the female caregivers. All of these negative outcomes of providing care for a loved one with dementia suggest a need for interventions to help ameliorate some of the emotional consequences of caregiving ( Family Caregiver Alliance: National Center on Caregiving, 2014 ).

   As awareness of caregiver burden has grown, much of the attention in terms of resources has been focused on supporting caregivers. New services (e.g., respite care) and support groups have the dual objectives of reducing caregiver burden and reducing the likelihood of institutionalizing the client.

   The following list includes some of the Internet resources available.

·   www.alz.org :The Alzheimer's Association is a leading non-profit, voluntary health organization in Alzheimer's care, support and research

·   www.nih.nia.gov : The National Institute on Aging site with links to research and publications regarding health issues and aging including Alzheimer's disease

·   www.ninds.nih.gov : The National Institute of Neurological Disorders and Stroke for information on a variety of neurological and cognitive disorders and stroke

·   www.caregiver.org : Family Caregiver Alliance for information and resources concerning caregivers of persons with cognitive disorders

Case 17.1

Identifying Information

Name: Della Corbin

Age: 72 years old

Ethnicity: Caucasian

Marital Status: Widowed

Intake Information

You are a social worker at a hospital located in a small town in the mountains of Tennessee. The nurse on the medical floor has asked you to evaluate a woman who was admitted to the hospital for possible nursing home placement. The nurse stated that Della Corbin was admitted 2 days ago. Her husband died a year ago, and she has a son who lives out of state. Her daughter lives in Memphis—a 6-hour drive from her mother's home. Mrs. Corbin apparently has many friends from her church, and several of them have been inquiring about her health. One close friend told the nurse that Mrs. Corbin was in good health until she moved into an apartment house following her husband's death.

Initial Interview

As you enter Mrs. Corbin's room, you immediately observe a very petite, fragile woman lying in bed with a white sheet and two green blankets covering her bed. She appears to be enveloped in the bedding. Upon closer examination, you notice that Mrs. Corbin has been restrained in her bed. Her arms are loosely tied to the bed railings, which are fully extended on each side of the bed. Mrs. Corbin appears alert but very agitated. Misty Wells, the nursing assistant, is feeding her applesauce, and Mrs. Corbin is spitting and yelling obscenities at her. The situation is much more chaotic than you expected.

   The nursing assistant is so intent on feeding Mrs. Corbin that she doesn't notice you entering the room. You quietly approach the bedside and ask the assistant why Mrs. Corbin is restrained. Misty jumps and appears surprised at your presence. She tells you that Mrs. Corbin has been “out of her head” since she was admitted to the hospital.

   “I don't think she even knows where she's at,” Misty tells you. “I think she believes she's at home. She's confused about who I am. Sometimes, she thinks I'm her daughter and that she's at home. This morning she was telling me to get her bathrobe out of the closet in the other bedroom, so I think she believes she's at her home.”

   “Okay. Is it all right if I try to talk with her for a few minutes?” you ask Misty.

   “Oh yes, please do. She's not making much sense though,” Misty replies.

   You tell Mrs. Corbin your name and that you are the social worker at the hospital. She glares at you and asks you where her Coca-Cola is.

   “Mrs. Corbin, I don't have your Coke. Would you like me to see if the nurse can get you a Coke?” you ask.

   “Well, I wouldn't really need it if I had my bathrobe. Where the hell is my doctor? He needs to find my bathrobe. If I had that bathrobe, I could go and get those philodendron plants that I love. Then I could finish decorating the living room for the holidays. That angel up top of the tree looks like Barbra Streisand.”

   You repeat, “Would you still like me to get you a Coke?”

   “I hate those goddamned commercials with the polar bears in 'em. Like that'll make someone want a soda, goddamn it! Those commercials just bug the crap out of me! I can't even believe you brought that up . . . look at my arms! Get these things off my arms! I'll call the cops if you don't get these damned things off my arms. And you keep asking about that soda? C'mere and I'll show you what I think of that Coke of yours.” She bares her teeth and spit flies.

   You back up a few feet since Mrs. Corbin is gnashing her teeth and spitting as she threatens you. You wonder what is wrong with this elderly woman. You have never observed this type of behavior in an older person even though you have worked with many dementia patients.

   Mrs. Corbin has been writhing restlessly in bed and pulling at her blankets since you entered the room. Suddenly, she bolts upright and says that she is going home. You attempt to calm her down by going to her side, but she then tries to bite you. She struggles to free herself from the bed. And suddenly she bursts into tears, crying, “I'm so tired. Why don't they let me out of here?”

   You explain to Mrs. Corbin that the doctors are trying to help her feel better and that you are going to help her find a good place to stay when she leaves. She looks wide-eyed and responds, “I can't move all my things. And what about my birds?”

   “Right now, you just need to rest and get better. Don't worry about your birds. Your son told me that he was taking care of them,” you attempt to reassure her.

   Mrs. Corbin lies back in the bed and turns her head away from you. She mutters, “Well, I just don't care what happens. And what do you know anyway?”

   You note the fact that Mrs. Corbin's emotions are erratic and extremely unstable at the moment. You decide to end the interview since it appears to be too difficult to establish rapport at this time.

   You go out to the nursing station to Mrs. Corbin's chart and discover that while you were talking with this client, the doctor has noted the possibility of lead poisoning and has ordered blood tests.

· 17.1–1 Whom else would you like to talk to about Mrs. Corbin's situation?

 

· 17.1–2 Looking back on the interview, is there anything you would have done differently? If so, what and why?

 

· 17.1–3 What potential diagnoses would you rule out?

 

· 17.1–4 What is your preliminary diagnosis?

 

· 17.1–5 List the psychosocial and cultural factors as V or Z codes that would apply to this case.

 

Case 17.2

Identifying Information

Name: Olivia Joyner

Age: Unknown, but elderly

Ethnicity: African-American

Marital Status: Widowed

Intake Information

You are the worker “on call” at the Goodheart Mental Health Center, which is located in a Southern town. You receive a call from local law enforcement that they are bringing an elderly African- American female in for evaluation. They had been contacted by personnel from the Greyhound bus station after they became concerned about her apparent confusion and continued presence for the past 36 hours.

Initial Contact

The client appears quite elderly and frail. She is dressed neatly in a checked dress with comfortable shoes. She seems rather alarmed and confused. She is clutching a small handbag.

   “Good morning, ma'am. What can I call you?” you begin.

   “My name is Olivia Joyner,” she responds.

   “I work here at the clinic and hope I can help you out today,” you say.

   “That's okay, honey. I just can't find the el. These police are scaring me some,” she whispers. “You can't be too careful, you know. White people can be real mean.”

   “I don't think he needs to stay if he's bothering you. Do you think I could look in your purse before he goes?” you ask.

   “What purse?” she responds, but she allows you to take her bag and hand it over to the officer.

   The officer finds an identification card in her purse indicating that she is 93 years old and resides in Gary, Indiana. The officer tells you he will try to get more information about her and leaves.

   “Well, Mrs. Joyner, would you tell me what you've been doing at the Greyhound station the last few days?”

   “Just call me Olivia, sweetie. Where's the el?” she responds. “I been wanting to do some real important shopping but then there's the weather. Can't fight city hall, you know.”

   You recognize that the “el” is a mass transit system in Chicago (not far from Gary, Indiana). “Okay, Olivia, where are you trying to get to?”

   The client seems to have lost track of the conversation and is looking anxiously around the interview room. “Have you seen my bag?” she asks. “I got to keep my things together. People can take advantage of you when you get old. Do you know what time it is?”

   When you return her handbag, she empties it and begins looking through its contents.

   “Olivia, have you eaten recently? Can I get you something to eat or drink?” you ask.

   She looks at you expectantly and then returns to her inspection of her handbag. “Strawberry shortcake is the best, don't you think?”

· 17.2–1 What diagnoses are you considering at this point?

 

   While you are getting Mrs. Joyner a sandwich and a glass of water, you pick up a message from the police officer who brought her in. He has contacted the Indiana State Patrol and confirmed that she was reported missing 6 days ago. He is attempting to contact relatives in that area.

   When you return to the client, she thanks you enthusiastically for the snack. “I just love lunch meats. When I was little, you know, we didn't have things like this. You have so many stores now. You can buy anything you want. And go to the bathroom wherever you want. Things sure are different these days.”

   “Mrs. Joyner, I mean Olivia, can you tell me how old you are?” you ask.

   “I'm not sure I know anymore. What year is this?” she responds. “I can't even keep track of the schedule anymore.”

   “Ma'am, do you know where you are?”

   She laughs softly. “I guess not since I can't find that station. I've been coming here most of my life, but everything just looks strange to me now.”

   “You're in Quitman, Georgia, at a clinic. Do you know how you got here?” you ask.

   The client looks somewhat alarmed and begins to cry. “I thought that bus ride was too long. I just want to get my baby a present. Did anyone feed my cat?”

   “Don't worry now. We'll make sure you get back home. Can you tell me how to contact a friend or a relative in Indiana?” you ask.

   The client stops crying and says, “Carter'll come get me. Can you call Carter?”

   “I'd be happy to call. Can you give me his number?” you ask.

   “It's 459. But I haven't got a present yet. It's his birthday tomorrow, you know.”

   You excuse yourself again to see if law enforcement has gotten any more information.

· 17.2–2 What diagnosis would you give Olivia Joyner at this point?

 

· 17.2–3 Other than contacting a family member, are there any other resources you would want to involve at this point?

 

Collateral Information

About an hour later, the police officer calls with a telephone number in Gary. He has contacted a Mrs. Carter Joyner, the client's daughter-in-law. You immediately call this relative.

   “Mrs. Joyner, I'm calling from Quitman about your mother-in-law, Olivia Joyner,” you begin.

   “Thank God. We've been so worried. She's been missing for a week now. Is she all right? Can I talk to her?” she asks.

   “She seems to be all right physically. I'll be happy to let you speak with her in a few minutes, but I need a little information first if you don't mind.” With her agreement, you continue. “Your mother-in-law seems a bit confused and disoriented. For example, she thought she was lost in Chicago, at least initially. Has she had problems with that kind of confusion before?”

   “Well, no. Olivia's as sharp as a nail. She takes Greyhounds into the city and then goes all over on the el. She handles her own money and everything. Most of the time, she has it better together than me. Do you think something's happened to her?” she asks.

   “I don't think she's been injured or anything. She may not have eaten or slept right for quite a while since we don't know what was going on with her for most of this week. Would you have any objections to me taking her to a medical doctor to have her checked?” you ask.

   “Not at all. I've called my husband, Carter, and he's on his way home from work. We'll be flying down just as soon as we figure out the details. Olivia should have her Medicare card with her. Will that be enough for someone there to see her?”

   “That should do it. I'll make arrangements to have her examined immediately. I'll call again in an hour or two so we can coordinate getting you all and Olivia back together.”

· 17.2–4 Based on this interaction, would you change your diagnosis for Olivia Joyner? If so, what would be your new diagnosis?

 

Emergency Room Contact

   After some calls, it seems clear that the most expedient way to get a medical examination of Olivia Joyner is to take her to the local hospital's emergency room. After you have waited roughly 30 minutes, an ER nurse comes out to speak with you.

   “We're going to be admitting Olivia to the hospital, so I need more information about contacting her relatives.”

   “Sure, I'd be happy to relay information as well. I last spoke with her daughter-in-law about an hour ago. She and Olivia's son planned on coming as soon as they could. Can you tell me what's going on with her?”

   “Well, at this point, it looks like she's had some sort of a brain bleed. I'm not sure whether it could technically be considered a stroke, but right now we're just trying to get her blood pressure back under control. Do you know whether she was taking antihypertensive medications?” she inquired.

   “All I can tell you is that she didn't have any medicines in her handbag. I'm afraid I didn't think to ask her daughter-in-law specifically, although she indicated that Mrs. Joyner was ‘healthy,'” you reply.

   “Well, we'll call her family now and take it from there.”

   “Great. Please let them know that they can contact me at the clinic if I can help them make arrangements,” you conclude.

· 17.2–5 What will be your “final” diagnosis for Olivia Joyner?

 

· 17.2–6 List the psychosocial and cultural factors as V or Z codes that would apply to this case.

 

Case 17.3

Identifying Information

Name: Mildred Perkins

Age: 75 years old

Ethnicity: Caucasian

Marital Status: Married

Occupation: Retired

Background Information

You work as a hospital social worker. As part of your job, you visit patients when referred by their doctors in order to help them and/or their families with resources and discharge planning.

Referral Information

Mildred Perkins is a 75-year-old woman recently hospitalized due to her newly diagnosed diabetic condition. Her daughter, Janet Fletcher, is a 44-year-old single mother of two children ages 15 and 17. Janet is a human resources administrator for the Parks and Recreation Department of a small city in the Midwest. She enjoys her job and gets along well with her children.

   Janet's parents, Mildred and Ray, lived in Pennsylvania most of their lives. They moved to the Midwest to be close to Janet when they were in their late 60s and after Janet had divorced her former husband. Mildred and Ray have remained very active in their retirement years. They own a recreational vehicle and have traveled extensively throughout the United States. Janet, an only child, has spent many hours at the hospital with her mother and 80-year-old father.

   While spending time with her mother at the hospital, Janet noticed that her mother was becoming increasingly forgetful. On one occasion when Janet arrived at her mother's room, Mildred asked Janet if she was a new nurse on the unit. This comment was very disturbing to Janet. She told her mother, “I'm not a nurse, Mother, I'm your daughter.”

   “Oh, of course you are,” her mother replied. “I just didn't have my glasses on and couldn't see you clearly.” Janet then asked her mother's doctor about the problem. He referred the family to you for an initial screening.

· 17.3–1 What diagnoses are you considering before you visit with Mildred?

 

Collateral Information

Before visiting the family, you stop in to see the nurse who is giving care to Mildred. She tells you that she has noticed that Mildred appears to be becoming increasingly disoriented. For example, it seems that Mildred sometimes forgets that she is in the hospital. On two occasions, the nurse walked into the room and found Mildred getting dressed. When the nurse asked her what she was doing, Mildred replied that she was going downstairs to have dinner.

   On another occasion, the nurse found Mildred attempting to use her toothbrush to cut her meat on her dinner tray. She seemed confused when the nurse suggested she use the knife instead of the toothbrush. The nurse also suggests that Mildred seems to get “agitated and edgy” for no apparent reason.

   You find a chart note from the morning nurse indicating that Mildred is making good progress on her recovery from her diabetic episode but that she rang her bell frequently all morning and was asking the same questions over and over again. The nurse found herself having to repeat things to Mildred that she had just told her a few minutes earlier. She was very concerned about sending Mildred home because Mildred was having a great deal of difficulty remembering the instructions the nurse had given her regarding the need to check her glucose levels at regular intervals. The morning nurse has been attempting to explain the process to Mildred for several days, but Mildred is unable to recall what the nurse has told her to do. The nurse also felt that, due to Ray's advanced age, he might not be able to help Mildred with the type of assistance that she would require at home.

   When you go to visit Mildred, she is not in her room but is wandering down the hall, apparently looking for someone. When you approach her and tell her your name, she states that she is looking for her room. You guide her back to her room and suggest the two of you talk about how she's been feeling and about going home.

   Mildred says that she's ready to go home. “I have been in this hospital for weeks and they won't let me out of here,” she states. When you ask her if she knows exactly how long she's been in the hospital, Mildred replies, “Since about June, I guess.”

   “And what month is it now?” you question.

   “I believe it's November, and I have to get the house ready for Christmas,” Mildred replies.

   “Actually, Mrs. Perkins, it is September and, from your records, it looks as if you've been in the hospital for about a week now,” you explain to her in a gentle and nonthreatening manner. “Do you know what year it is?” you query.

   Mildred replies, “I believe it's 1995, isn't it?”

   “Well, actually, this is the year 2000, Mrs. Perkins,” you respond.

   “Oh yes, I couldn't quite remember. You know it's harder to remember these things when you get older like me,” Mildred suggests.

   “What about children, Mrs. Perkins. Do you have any children?” you ask.

   “Yes, my daughter, Janet, works for the Parks and Recreation Department. She is very good at her job.”

   “And has Janet come by to see you in the hospital?” you inquire.

   “I don't think she's had the time. You know she has children of her own that take up a lot of her time,” Mildred replies.

   “What about your husband? Has he come to see you while you've been in the hospital?” you ask.

   “Yes, I believe he came to see me yesterday,” Mildred responds.

   “Do you know who the president of the United States is this year, Mrs. Perkins?” you inquire.

   Mildred stares at her hands, and after a long pause she suggests that it must be President Reagan. She again states that she really needs to get home since Christmas is right around the corner. Mildred then gets up and begins taking her belongings out of the drawers and placing them on the bed. She takes the trash can and begins placing all her things in the trash.

   When you ask her what she is doing, she states that she's packing to go home. Mildred looks rather perplexed about the trash can but continues to pile her clothing in the bin. She then appears to realize that her clothes don't belong in the trash can and begins taking them out. She states that all her clothes won't fit in that small suitcase and that she needs her larger suitcase so everything will fit.

   You suggest that it might be a good idea to wait until the doctor has seen her before she begins to pack her suitcase. Mildred looks astonished and asks why she needs to see a doctor. You tell her that she's in the hospital and that she's there in order to get her diabetes under control. Mildred looks confused and sits down on the bed again.

   “I just don't know what's happening to me these days. I think I'm losing track of things,” Mildred states.

   You suggest that perhaps a doctor can help her sort things out so she will feel better. You tell her that you'll come back to see her again and that maybe she'd like to rest for a while.

   With your encouragement, Mildred lies back down on the bed and states that she is feeling very tired.

· 17.3–2 What other information would you like to have? Whom else would you like to interview? Are there any other consultations you'd like to arrange?

 

· 17.3–3 What would be your preliminary diagnosis?

 

· 17.3–4 List the psychosocial and cultural factors as V or Z codes that would apply to this case.

 

Follow-Up Information

Based on your report, Mildred's primary physician calls in a neurologist for consultation. While waiting for Mildred's evaluation, her daughter and husband ask to meet with you to plan for the future.

· 17.3–5 How will you assess the strengths of the family?

 

· 17.3–6 What questions are important for the family to consider in making discharge plans for Mildred?

 

Differential Diagnosis

Perhaps one of the most frequently encountered issues in making a diagnosis of NCDs in older people is that memory impairment is often a normal aspect of aging and not necessarily a symptom of a mental disorder. Determining what is normal aging and what constitutes NCDs is related to a variety of factors, including level of severity, patterns of behavior, length of problem, and other medical conditions.

   In addition, persons with NCDs and persons with Delirium may have problems with memory. What distinguishes Delirium from NCDs is the symptom of reduced consciousness and the fluctuating nature of symptoms.

· 17.DD–1 What are some differences between Della Corbin and Mildred Perkins?

 

· 17.DD–2 Write a case scenario in which the individual has normal problems with aging but would need further evaluation or testing to “rule out” NCDs.

 

· 17.DD–3 When Della Corbin becomes coherent, what additional questions would you want to ask her to rule out other cognitive disorders?

 

References

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