Constructing Clinical Reasoning SkillsConstructing Clinical Reasoning Skills Using a Problem-Based Learning PrototypeUsing a Problem-Based Learning Prototype

P. Alex Mabe, Ph. D.P. Alex Mabe, Ph. D.ProfessorProfessor

Department of Psychiatry and Health BehaviorDepartment of Psychiatry and Health Behavior

Medical College of GeorgiaMedical College of Georgia

Workshop Workshop ObjectivesObjectives

Examine the domain of clinical reasoning.Examine the domain of clinical reasoning. Provide an overview of Problem-Based Provide an overview of Problem-Based

Learning models in teaching clinical Learning models in teaching clinical reasoning. reasoning.

Present an adaptation of Problem-Based Present an adaptation of Problem-Based Learning designed to teach clinical Learning designed to teach clinical reasoning to predoctoral interns/residents. reasoning to predoctoral interns/residents.

Acknowledgement Acknowledgement

Nettie Albrecht, Ph.D.Nettie Albrecht, Ph.D.Co-Creator/Co-Director of the Co-Creator/Co-Director of the

Diagnostic/Treatment Seminar - PBLDiagnostic/Treatment Seminar - PBL

VAMC Training Director for theVAMC Training Director for theMCG-VAMC Psychology Residency ConsortiumMCG-VAMC Psychology Residency Consortium

Staff Psychologist, VAMC of AugustaStaff Psychologist, VAMC of AugustaAssistant Clinical Professor of Psychiatry, MCGAssistant Clinical Professor of Psychiatry, MCG

DisclaimerDisclaimer

Components of Clinical Components of Clinical

ExpertiseExpertise ExpertsExperts ““Experts recognize meaningful patterns and Experts recognize meaningful patterns and

disregard irrelevant information, acquire extensive disregard irrelevant information, acquire extensive knowledge and organize it in ways that reflect a knowledge and organize it in ways that reflect a deep understanding of their domain, organize their deep understanding of their domain, organize their knowledge using functional rather than descriptive knowledge using functional rather than descriptive features, retrieve knowledge relevant to the task at features, retrieve knowledge relevant to the task at hand fluidly and automatically, adapt to new hand fluidly and automatically, adapt to new situations, self-monitor their knowledge and situations, self-monitor their knowledge and performance, know when their knowledge is performance, know when their knowledge is inadequate, continue to learn, and generally attain inadequate, continue to learn, and generally attain outcomes commensurate with their expertise.”outcomes commensurate with their expertise.” (p.276)(p.276)

APA Presidential Task Force on Evidence Based Practice APA Presidential Task Force on Evidence Based Practice (2006) Evidenced-based practice in psychology. (2006) Evidenced-based practice in psychology. American American PsychologistPsychologist,, 61 61, 271-285, 271-285.

Components of Clinical Components of Clinical

Expertise - continuedExpertise - continued (a) assessment, diagnostic judgment, systematic case (a) assessment, diagnostic judgment, systematic case

formulation, and treatment planning; formulation, and treatment planning; (b) clinical decision making, treatment implementation, (b) clinical decision making, treatment implementation,

and monitoring of patient progress; and monitoring of patient progress; (c) interpersonal expertise; (c) interpersonal expertise; (d) continual self-reflection and acquisition of skills; (d) continual self-reflection and acquisition of skills; (e) appropriate evaluation and use of research evidence (e) appropriate evaluation and use of research evidence

in both basic and applied psychological science; in both basic and applied psychological science; (f) understanding the influence of individual and cultural (f) understanding the influence of individual and cultural

differences on treatment; differences on treatment; (g) seeking available resources (e.g., consultation, (g) seeking available resources (e.g., consultation,

adjunctive or alternative services) as needed; adjunctive or alternative services) as needed; and (h) having a cogent rationale for clinical strategies.and (h) having a cogent rationale for clinical strategies.(p. 276)(p. 276)

APA Presidential Task Force on Evidence Based Practice APA Presidential Task Force on Evidence Based Practice (2006) Evidenced-based practice in psychology. (2006) Evidenced-based practice in psychology. American American PsychologistPsychologist,, 61 61, 271-285., 271-285.

Components of Clinical Components of Clinical

Expertise - continuedExpertise - continued competence iscompetence is "the habitual and judicious use of "the habitual and judicious use of

communication, knowledge, technical skills, communication, knowledge, technical skills, clinical reasoning, emotions, values, and clinical reasoning, emotions, values, and reflection in daily practice for the benefit of the reflection in daily practice for the benefit of the individual and community being served" individual and community being served" (Epstein & Hundert, 2000,p. 227). They further (Epstein & Hundert, 2000,p. 227). They further asserted that competence depends on habits of asserted that competence depends on habits of mind, including attentiveness, critical curiosity, mind, including attentiveness, critical curiosity, self-awareness, and presence. (p.775)self-awareness, and presence. (p.775)

As such, competence connotes the capability of As such, competence connotes the capability of critical thinking and analysis…critical thinking and analysis…

Kaslow NJ (2004) Competencies in professional psychology. Kaslow NJ (2004) Competencies in professional psychology. American PsychologistAmerican Psychologist, , 5959, 774-781., 774-781.

Conclusions:Conclusions:

Clinical reasoning is a core Clinical reasoning is a core competency of professional competency of professional psychologists.psychologists.

Teaching clinical reasoning Teaching clinical reasoning appears to be a complex task. appears to be a complex task.

How Psychologists ThinkHow Psychologists ThinkThinking like a psychologist is based on a combination of factors Thinking like a psychologist is based on a combination of factors

including:including: (a) critical thinking and logical analysis; (a) critical thinking and logical analysis; (b) being conversant with and utilizing scientific inquiry and (b) being conversant with and utilizing scientific inquiry and

professional literature; professional literature; (c) being able to conceptualize problems and issues from multiple (c) being able to conceptualize problems and issues from multiple

perspectives (e.g., biological, pharmacological, intrapsychic, perspectives (e.g., biological, pharmacological, intrapsychic, familial, organizational/systems, social, cultural); familial, organizational/systems, social, cultural);

and (d) being able to access, understand, integrate, and use and (d) being able to access, understand, integrate, and use resources (e.g., empirical evidence, statistical approaches, resources (e.g., empirical evidence, statistical approaches, technology, collegial consultation). technology, collegial consultation).

(p. 369)(p. 369)Elman NS, Illfelder-Kaye J, & Robiner WN (2005) Professional development: training for professionalism Elman NS, Illfelder-Kaye J, & Robiner WN (2005) Professional development: training for professionalism as a foundation for competent practice in psychology. as a foundation for competent practice in psychology. Professional Psychology: Research and PracticeProfessional Psychology: Research and Practice, , 36, 36, 367-375.367-375.

Teaching Teaching Psychologists Psychologists

How to How to Think…Think…

It’s a daunting It’s a daunting task!task!

Critical thinking and Clinical ReasoningCritical thinking and Clinical Reasoning Critical thinkingCritical thinking – actively and skillfully – actively and skillfully

conceptualizing, applying, synthesizing and conceptualizing, applying, synthesizing and evaluating information…evaluating information…

Clinical reasoningClinical reasoning – – all thatall that plus have a plus have a knowledge of “illness”, “illness scripts”, illness knowledge of “illness”, “illness scripts”, illness trajectories, etiology as well as description, and trajectories, etiology as well as description, and the integration of problem understanding with the integration of problem understanding with problem solution. problem solution.

Research Regarding Research Regarding DiagnosticDiagnostic Reasoning Reasoning Success in diagnosing one problem has Success in diagnosing one problem has

been shown to be a poor predictor of been shown to be a poor predictor of success in diagnosing another. success in diagnosing another.

Content specificity has been critical in Content specificity has been critical in successful diagnostic reasoning. successful diagnostic reasoning.

Pattern recognition appears to be key to Pattern recognition appears to be key to diagnostic efficiency and accuracy. diagnostic efficiency and accuracy.

Research Regarding Research Regarding DiagnosticDiagnostic Reasoning – Reasoning –

the development of clinical reasoning the development of clinical reasoning Expertise is not a matter of acquiring some kind of Expertise is not a matter of acquiring some kind of

general, all inclusive reasoning strategy. general, all inclusive reasoning strategy. Knowledge counts … no one kind of knowledge Knowledge counts … no one kind of knowledge

counts more than any other. counts more than any other. Expertise (in medicine) is derived from both formal Expertise (in medicine) is derived from both formal

and experiential knowledge. and experiential knowledge. The process of pattern recognition so characteristic The process of pattern recognition so characteristic

of an “expert’s approach appears to be a product of of an “expert’s approach appears to be a product of extensive experience with patients overlaid on formal extensive experience with patients overlaid on formal knowledge structure. knowledge structure.

Geoffrey N (2006) Building on experience – The development of clinical Geoffrey N (2006) Building on experience – The development of clinical reasoning. reasoning. The New England Journal of MedicineThe New England Journal of Medicine, , 355355, 2251-2252., 2251-2252.

General Training Recommendations:General Training Recommendations: The Development of Clinical ReasoningThe Development of Clinical Reasoning

Encourage students to use both analytical rule Encourage students to use both analytical rule knowledge and experiential knowledge. knowledge and experiential knowledge.

Provide clinical reasoning experience. A Provide clinical reasoning experience. A critical element of becoming an expert is critical element of becoming an expert is accruing the experience that enables experts accruing the experience that enables experts to recognize patterns. to recognize patterns.

Help students make the connection between Help students make the connection between “basic science” and specific clinical “basic science” and specific clinical encounters. encounters.

Elements of the Clinical Reasoning ProcessElements of the Clinical Reasoning Process

Data acquisition.Data acquisition. Data organization.Data organization. Data abstraction.Data abstraction.

– Hypothetico-deductive method – experts Hypothetico-deductive method – experts produce better hypotheses. produce better hypotheses.

– Schema development. Schema development. – Illness scripts. Illness scripts.

Elements of the Clinical Reasoning Process- Elements of the Clinical Reasoning Process- continuedcontinued

Case formulationCase formulation– Comprehensive.Comprehensive.– Precise.Precise.– Integrated.Integrated.– Coherent. Coherent. – SystematicSystematic– Goodness-of-fit (problem definition and Goodness-of-fit (problem definition and

treatment)treatment)

Elements of the Clinical Reasoning Process- Elements of the Clinical Reasoning Process- continuedcontinued

Self-monitoring skills.Self-monitoring skills. Effective use of available resources. Effective use of available resources.

– Evidence based practice. Evidence based practice. – Information management. Information management.

Teaching Clinical Reasoning-Teaching Clinical Reasoning-

Criticisms of Traditional Criticisms of Traditional Teaching MethodsTeaching Methods

Information overload.Information overload. Passive transfer of expert knowledge.Passive transfer of expert knowledge. Emphasis on knowledge as opposed to Emphasis on knowledge as opposed to

skill and attitudes.skill and attitudes.

Teaching Clinical Teaching Clinical Reasoning-Reasoning-

Adult LearningAdult Learning

Adults have a foundation of life Adults have a foundation of life experiences and knowledge.experiences and knowledge.

Adults are goal directed. Adults are goal directed. Adults are relevancy-oriented. Adults are relevancy-oriented. Adults must be shown respect.Adults must be shown respect.

Problem Based Learning Problem Based Learning (PBL)(PBL)

Problem-based learning (PBL) is a method Problem-based learning (PBL) is a method of teaching first adopted in undergraduate of teaching first adopted in undergraduate medical education by McMaster University medical education by McMaster University in the mid-1960s. in the mid-1960s.

Currently, more than 90 medical schools Currently, more than 90 medical schools worldwide have incorporated some form worldwide have incorporated some form of PBL in their undergraduate curricula. of PBL in their undergraduate curricula.

Studies have shown that PBL can be a Studies have shown that PBL can be a more successful approach compared with more successful approach compared with more traditional curricula with regard to:more traditional curricula with regard to:– intrinsic motivationintrinsic motivation– improving problem-solving skills/clinical improving problem-solving skills/clinical

reasoning reasoning – long-term retention of learned knowledge long-term retention of learned knowledge

Common Components of Common Components of PBL InstructionPBL Instruction

Small group instruction. Small group instruction. A gradually evolving clinical A gradually evolving clinical

problem is presented. problem is presented. Think out loud strategies are Think out loud strategies are

employed. employed. Discussion and clinical reasoning Discussion and clinical reasoning

are primarily self-directed although are primarily self-directed although facilitators are present to assist.facilitators are present to assist.

Identification of learning issues.Identification of learning issues. Summarizing what has been Summarizing what has been

learned.learned.

Aims of PBL InstructionAims of PBL Instruction

Activation and elaboration of prior Activation and elaboration of prior knowledge. knowledge.

Acquisition and integration of Acquisition and integration of scientific and clinical knowledge.scientific and clinical knowledge.

Restructuring prior knowledge. Restructuring prior knowledge. Developing clinical reasoning in Developing clinical reasoning in

context.context. Triggering curiosity and habits of Triggering curiosity and habits of

lifelong learning.lifelong learning.

PBL Instruction:PBL Instruction:Thinking Out LoudThinking Out Loud

““What do you know?”What do you know?” What do you need to know?”What do you need to know?” ““Why do you need to know…?”Why do you need to know…?” ““What are your hypotheses?What are your hypotheses? ““What are your learning issues?”What are your learning issues?”

PBL Instruction:PBL Instruction:ContentContent Material SelectedMaterial Selected

Often part of a core curriculum in Often part of a core curriculum in integrating basic and clinical integrating basic and clinical sciences. sciences.

Paper based scenarios are more Paper based scenarios are more common because of the common because of the consistency of material consistency of material presented. presented.

Levels of difficulty/complexity Levels of difficulty/complexity often are progressively often are progressively introduced.introduced.

PBL Instruction:PBL Instruction:An Unfolding CaseAn Unfolding Case

Bridget is a 14year-old, biracial adolescent Bridget is a 14year-old, biracial adolescent who initially presents with Major Depressive who initially presents with Major Depressive Disorder with Psychotic Features, but Disorder with Psychotic Features, but subsequently develops a manic episode, subsequently develops a manic episode, changing her diagnosis to Bipolar Disorder. changing her diagnosis to Bipolar Disorder. She has multiple risk factors for suicide, She has multiple risk factors for suicide, and many attempts. She is also very and many attempts. She is also very sensitive to medication, and goes through sensitive to medication, and goes through trials of multiple antidepressants and mood trials of multiple antidepressants and mood stabilizers. She is hospitalized when she stabilizers. She is hospitalized when she takes an overdose of her mother's triiyclic takes an overdose of her mother's triiyclic antidepressants. (p.150)antidepressants. (p.150)

Zisook S, Benjamin S, Balon R, Glick R, Louie A, Moutier C, Moyer T, Santos C & Servis M (2005) Zisook S, Benjamin S, Balon R, Glick R, Louie A, Moutier C, Moyer T, Santos C & Servis M (2005) Alternative methods of teaching psychopharmacology. Alternative methods of teaching psychopharmacology. Academic PsychiatryAcademic Psychiatry, , 29 29, 141-154. , 141-154.

PBL Instruction:PBL Instruction:An Unfolding Case-An Unfolding Case- continued continued

After obtaining consent from Bridget After obtaining consent from Bridget and her family, you begin to treat and her family, you begin to treat Bridget with carbamazepine and Bridget with carbamazepine and haloperidol. The family is actively haloperidol. The family is actively involved in family therapy. Five days involved in family therapy. Five days later in report, the nursing staff later in report, the nursing staff informs you that Bridget has informs you that Bridget has developed a pruritic rash. When you developed a pruritic rash. When you evaluate this, you discover an evaluate this, you discover an erythematous, macutopapular erythematous, macutopapular eruption on the trunk eruption on the trunk andextremities. (p.150)andextremities. (p.150)

Zisook S, Benjamin S, Balon R, Glick R, Louie A, Moutier C, Moyer T, Santos C & Servis M (2005) Zisook S, Benjamin S, Balon R, Glick R, Louie A, Moutier C, Moyer T, Santos C & Servis M (2005) Alternative methods of teaching psychopharmacology. Alternative methods of teaching psychopharmacology. Academic PsychiatryAcademic Psychiatry, , 29 29, 141-154., 141-154.

PBL Instruction:PBL Instruction:An Unfolding Case-An Unfolding Case- continued continued

Bridget is very upset about the rash and Bridget is very upset about the rash and accuses you of causing it. She subsequently accuses you of causing it. She subsequently begins to refuse all scheduled medication begins to refuse all scheduled medication despite your best efforts to address her despite your best efforts to address her concerns. Her behavior and thought concerns. Her behavior and thought processes remain disorganized and she is processes remain disorganized and she is constantly disruptive on the unit. Her constantly disruptive on the unit. Her parents are quite worried and ask you why parents are quite worried and ask you why don't just make her take the medications don't just make her take the medications since you hove their permission to give since you hove their permission to give them and since Bridget is an involuntary them and since Bridget is an involuntary patient. (p.150)patient. (p.150)

Zisook S, Benjamin S, Balon R, Glick R, Louie A, Moutier C, Moyer T, Santos C & Servis M (2005) Zisook S, Benjamin S, Balon R, Glick R, Louie A, Moutier C, Moyer T, Santos C & Servis M (2005) Alternative methods of teaching psychopharmacology. Alternative methods of teaching psychopharmacology. Academic PsychiatryAcademic Psychiatry, , 29 29, 141-154. , 141-154.

PBL Instruction:PBL Instruction:How well has it achieved it’s aims?How well has it achieved it’s aims?

PBL students do as well as PBL students do as well as lecture-based learning lecture-based learning counterparts on knowledge counterparts on knowledge acquisition. acquisition.

PBL students tend to perform PBL students tend to perform better on measures of reasoning better on measures of reasoning and learning strategies.and learning strategies.

Increased use of learning Increased use of learning resources and more reading for resources and more reading for meaning. meaning.

Challenges in Using PBL for Challenges in Using PBL for Training Professional PsychologistsTraining Professional Psychologists

Psychological problems are highly complex. Psychological problems are highly complex. Problems are often poorly defined, and Problems are often poorly defined, and

presented in a confusing and contradictory presented in a confusing and contradictory manner.manner.

Etiology of problems are multi-determined and Etiology of problems are multi-determined and often not well understood.often not well understood.

Instruction time for the content that needs to Instruction time for the content that needs to be taught is limited. be taught is limited.

Our PBL Prototype for Our PBL Prototype for Internship TrainingInternship Training

Components of traditional PBL that are Components of traditional PBL that are maintained:maintained:– Small group instruction. Small group instruction. – A gradually evolving clinical problem is A gradually evolving clinical problem is

presented. presented. – Think out loud strategies are employed. Think out loud strategies are employed. – Identification of learning issues.Identification of learning issues.– Summarizing what has been learned. Summarizing what has been learned.

Our PBL PrototypeOur PBL Prototype Modifications of traditional PBL:Modifications of traditional PBL:

The unfolding case is presented in the The unfolding case is presented in the form of videoed interviews plus form of videoed interviews plus additional case/ psychological additional case/ psychological assessment information. assessment information.

Guided discovery is emphasized, and in Guided discovery is emphasized, and in addition to facilitators the case “expert” addition to facilitators the case “expert” is present and assists in case discussion is present and assists in case discussion and formulation. and formulation.

Our PBL PrototypeOur PBL Prototype Modifications of traditional:Modifications of traditional: ccontinuedontinued

When learning issues are discovered, the When learning issues are discovered, the facilitators guide the students in regard to facilitators guide the students in regard to sources of “expertise” that might be available. sources of “expertise” that might be available.

Processing of the case discussion is Processing of the case discussion is emphasized each session in order to emphasized each session in order to encourage an attitude of reflection.encourage an attitude of reflection.

Case conceptualization is emphasized and Case conceptualization is emphasized and routinely practiced. routinely practiced.

Our PBL PrototypeOur PBL Prototype Modifications of traditional:Modifications of traditional: ccontinuedontinued

Expert critiques of the case Expert critiques of the case conceptualization are provided.conceptualization are provided.

““PBL” is followed by didactics on the PBL” is followed by didactics on the knowledge base needed to understand knowledge base needed to understand and treat the patient problem(s) at hand. and treat the patient problem(s) at hand.

Case DemonstrationCase Demonstration

13 year-old presents with her 13 year-old presents with her mother.mother.

What you know?What you know?

Relevant versus irrelevant data. Relevant versus irrelevant data. Distinguishing between data versus Distinguishing between data versus

inference. inference. Organization of the data to facilitate a Organization of the data to facilitate a

biopsychosocial examination of the data at biopsychosocial examination of the data at hand and to facilitate recognition of hand and to facilitate recognition of schemas and illness scripts. schemas and illness scripts.

What you know?What you know?Progression with PBL Training-Progression with PBL Training-

First Module to the Most Recent ModuleFirst Module to the Most Recent Module What we know? – first session What we know? – first session 15 y.o white male15 y.o white male Lives with mother/father and 12y.o. sisterLives with mother/father and 12y.o. sisterProblems 1Problems 1stst noted in K. noted in K.Previous Meds. Ritalin & ProzacPrevious Meds. Ritalin & ProzacHistory of oppositional behavior and low frustration tolerance (crying and kicking the History of oppositional behavior and low frustration tolerance (crying and kicking the

walls)walls)Behavior problems seem situationally specific (only with parents)Behavior problems seem situationally specific (only with parents)Dx of ADHD – in special ed.Dx of ADHD – in special ed.Emotional problems, dysgraphiaEmotional problems, dysgraphiaMom-Pt’s Perceptions skewed, no hallucinations.Mom-Pt’s Perceptions skewed, no hallucinations.Current medication – AbilifyCurrent medication – AbilifyIn therapy for 5 years, but not currently. In therapy for 5 years, but not currently. Participated in the CARE program – intensive otpt intervention. Participated in the CARE program – intensive otpt intervention. Father’s belief – pt is “faking” sometimes and has serious “meltdowns.” Father’s belief – pt is “faking” sometimes and has serious “meltdowns.” Treatment for depression with ProzacTreatment for depression with ProzacParticipates in several activities with church. Participates in several activities with church. Not oppositional in settings where parents are not present.Not oppositional in settings where parents are not present.Avoidance and lack of motivation.Avoidance and lack of motivation.Motivation concerns: minimal efforts on homework, no extra work or chores.Motivation concerns: minimal efforts on homework, no extra work or chores.Exhibits kicking. Exhibits kicking. Interventions (separation) have been successful.Interventions (separation) have been successful.Attention/concentration problems Attention/concentration problems

What you know?What you know?Progression with PBL TrainingProgression with PBL Training

What we know? – What we know? – Second session Second session -15 year old white male-15 year old white malePeer / Family RelationsPeer / Family RelationsFriends are younger, not intimate, no strong preferences.Friends are younger, not intimate, no strong preferences.Mom and Dad – Pt upset by parental control/structure.Mom and Dad – Pt upset by parental control/structure. Different parental perceptions – overstimulated versus “getting his way”, try to accommodate to decrease tension.Different parental perceptions – overstimulated versus “getting his way”, try to accommodate to decrease tension.Sister- pt bullies her, physically rough with her, but is “crazy about her.”Sister- pt bullies her, physically rough with her, but is “crazy about her.”

SymptomsSymptomsFixation on specific clothing, rigidity – only will watch certain TV channels. Fixation on specific clothing, rigidity – only will watch certain TV channels. Avoidance of novel situations, persistent crying to mild stressors. Avoidance of novel situations, persistent crying to mild stressors. Low frustration tolerance. Low frustration tolerance. In attention – “inner hyperactivity”; reports difficulty paying attentionIn attention – “inner hyperactivity”; reports difficulty paying attentionSocial anxiety – has difficulty speaking in front of groups, gets nervous around others, fearful of embarassing himself, shy with Social anxiety – has difficulty speaking in front of groups, gets nervous around others, fearful of embarassing himself, shy with

girls. girls. Feels sad, tired, fearful of break-ins, Worried that others are mad at him. Feels sad, tired, fearful of break-ins, Worried that others are mad at him. Scared of a spooky chapel, Scared of a spooky chapel, Thinks he is a “weakling”. Thinks he is a “weakling”. Has lots of negative self-perceptions. Has lots of negative self-perceptions. Has a hard time enjoying things. Has a hard time enjoying things.

Academic HistoryAcademic HistoryIs in the 9Is in the 9thth grade. grade. Retained 1 year. Retained 1 year. Improved school performance last year, but decreased performance this year. Improved school performance last year, but decreased performance this year. Reading and writing difficulties.Reading and writing difficulties.In special education because, “I have troubled concentrating.” In special education because, “I have troubled concentrating.”

What you know?What you know?Progression with PBL TrainingProgression with PBL Training

What we know? – What we know? – 13-year old with Eating Disorder - 13-year old with Eating Disorder - 11st st sessionsessionDemographic Info:Demographic Info:13 y.o. cauc female, presents with her mother.13 y.o. cauc female, presents with her mother.5’3” – 102 lbs.5’3” – 102 lbs.1 sister 11 y.o.1 sister 11 y.o.

Symptoms/Presenting ProblemSymptoms/Presenting Problem““Mom thinks I throw up too much”. – Made me come.Mom thinks I throw up too much”. – Made me come.Current weight – 102 lbs./low adolescent wght = 95-96 lbs.Current weight – 102 lbs./low adolescent wght = 95-96 lbs.Binges – 2x/wk, purges – 2x/day, chews/spits foods- occasionally.Binges – 2x/wk, purges – 2x/day, chews/spits foods- occasionally.Denied laxative /diet pill use. Pt knows her symptoms anger mom.Denied laxative /diet pill use. Pt knows her symptoms anger mom.Restricting diet x2 years – no high fat/high calorieRestricting diet x2 years – no high fat/high calorieBody Image – ideal weight is 95 lbs, stomach “too poochy”, satisfied with rest of body. Body Image – ideal weight is 95 lbs, stomach “too poochy”, satisfied with rest of body. Irregular menstrual cycles, Irregular menstrual cycles, Difficulty distinguishing hunger from satiety, eats when bored not when anxious (will get sick)Difficulty distinguishing hunger from satiety, eats when bored not when anxious (will get sick)Wears baggy clothes.Wears baggy clothes.Has a temper – throws tantrums. Has a temper – throws tantrums.

Medical/Psychiatric History Medical/Psychiatric History Trauma HistoryTrauma HistoryTreated at MCG EFAPTreated at MCG EFAPAlways had “nervous stomach”Always had “nervous stomach”Threw up “every day” in 6Threw up “every day” in 6thth grade when going to school grade when going to school

Family/Social Family/Social HistoryHistory Developmental/Academic HistoryDevelopmental/Academic History

Friend died 5 months ago. Friend died 5 months ago. Boyfriend broke up with her 2 months ago.Boyfriend broke up with her 2 months ago.Friend have gone to High School - new friends/peer group. Friend have gone to High School - new friends/peer group.

Substance UseSubstance Use Family Medical/Psychiatric HistoryFamily Medical/Psychiatric HistorySmoking (tobacco)Smoking (tobacco)

StrengthsStrengths Mental Status ExamMental Status Exam

What you need to know?What you need to know?Inquiry based on hypotheses, Inquiry based on hypotheses, schemas, and illness scriptsschemas, and illness scripts

Emphasis is on inquiry that is Emphasis is on inquiry that is data drivendata driven – not just a question that you would – not just a question that you would routinely ask. routinely ask.

Focuses on Focuses on relevant inquiryrelevant inquiry guided by guided by hypothetico-deductive reasoning, schema hypothetico-deductive reasoning, schema development, and/or illness scripts.development, and/or illness scripts.

Can develop precision in the questions Can develop precision in the questions that are being asked of the patient.that are being asked of the patient.

What you need to know?What you need to know?Progression with PBL TrainingProgression with PBL Training

What you need to know? – What you need to know? – first session-first session-15 y.o white male 15 y.o white male

What does mom’s statement that the patient’s What does mom’s statement that the patient’s “perceptions are skewed” mean? “perceptions are skewed” mean?

Why therapy stopped at age 10?Why therapy stopped at age 10?

When was the cognitive testing done and why?When was the cognitive testing done and why?

How does he function well in other environments but How does he function well in other environments but not at home? not at home?

What you need to know?What you need to know?Progression with PBL TrainingProgression with PBL Training

What you need to know? – What you need to know? – second sessionsecond session 15 y.o white male 15 y.o white male

Is the patient’s disruption because of loss of Is the patient’s disruption because of loss of friendship versus disruptions in routine?friendship versus disruptions in routine?

““Skewed perception” – difficulty with social cues, Skewed perception” – difficulty with social cues, interpretation, or poor judgment in general?interpretation, or poor judgment in general?

Are there weird obsessions? Preoccupation with Are there weird obsessions? Preoccupation with restricted focus? Any repetitive or stereotypical restricted focus? Any repetitive or stereotypical behaviors? behaviors?

What is “inner hyperactivity” – is it racing thoughts What is “inner hyperactivity” – is it racing thoughts or obsessional thinking?or obsessional thinking?

What you need to know?What you need to know?Progression with PBL TrainingProgression with PBL Training

What you need to know -What you need to know -13-year old with 13-year old with Eating Disorder- Eating Disorder- 11st st sessionsession

What is the relationship between mood and eating What is the relationship between mood and eating behavior? behavior?

Why is treatment being sought now? (was 95 lbs but Why is treatment being sought now? (was 95 lbs but now is 102 lbs)now is 102 lbs)

How is the eating behavior affecting functioning/ How is the eating behavior affecting functioning/ interference with life?interference with life?

What family dynamics were associated with the onset What family dynamics were associated with the onset of symptoms? (conflict resolution style? Is Mom of symptoms? (conflict resolution style? Is Mom permissive? Where’s dad? How is parental permissive? Where’s dad? How is parental involvement/control connecting to the eating involvement/control connecting to the eating behavior?)behavior?)

““Why do you need to Why do you need to know…?”know…?”

Think Out Loud ReasoningThink Out Loud Reasoning

Forces the learner to articulate the Forces the learner to articulate the hypothesis or theory underlying hypothesis or theory underlying inquiry.inquiry.

Sets up the opportunity for analyses Sets up the opportunity for analyses that either confirm or disconfirm the that either confirm or disconfirm the hypothesis or theory.hypothesis or theory.

Why you need to know…?Why you need to know…?Progression with PBL TrainingProgression with PBL Training

Why you need to know…? -Why you need to know…? -first session-first session-15 y.o white male 15 y.o white male

What does mom’s statement that the patient’s What does mom’s statement that the patient’s “perceptions are skewed” mean? – “perceptions are skewed” mean? – Could Could determine differential diagnoses such as: determine differential diagnoses such as: psychotic versus anxiety versus cognitive deficits psychotic versus anxiety versus cognitive deficits versus poor judgment. versus poor judgment.

Why you need to know…?Why you need to know…?Progression with PBL TrainingProgression with PBL Training

Why you need to know…? -Why you need to know…? -first session-first session-13-year old with eating disorder13-year old with eating disorder

What is the relationship between mood and eating What is the relationship between mood and eating behavior? – behavior? – Could help to identify triggers/ Could help to identify triggers/ patterns and establish a functional analysis of the patterns and establish a functional analysis of the disordered eating behaviors. disordered eating behaviors.

““What are your What are your hypotheses?”hypotheses?”

Functional or etiological theories/models are Functional or etiological theories/models are encouraged and not just DSM-IV descriptive encouraged and not just DSM-IV descriptive diagnoses. diagnoses.

Requires understanding of the etiological factors Requires understanding of the etiological factors of illness or problem, familiarity with descriptive of illness or problem, familiarity with descriptive diagnosis criteria, knowledge of illness diagnosis criteria, knowledge of illness trajectories and probabilities, and consideration trajectories and probabilities, and consideration of treatment options.of treatment options.

What are your hypotheses?What are your hypotheses?Progression with PBL TrainingProgression with PBL Training

What are your hypotheses? -What are your hypotheses? -first session-first session-15 y.o white male 15 y.o white male

Differing perspectives between the mom and dad – Differing perspectives between the mom and dad – “can’t help it versus he can”“can’t help it versus he can”

Ruleout: Ruleout:

Asperger’s DisorderAsperger’s Disorder

OCDOCD

Schizoaffective Disorder Schizoaffective Disorder

What are your hypotheses?What are your hypotheses?Progression with PBL TrainingProgression with PBL Training

What are your hypotheses? -What are your hypotheses? -first session-first session-13 year old with eating disorder13 year old with eating disorder

Ruleout: Ruleout: Eating Disorder, N.o.s. versus BulimiaEating Disorder, N.o.s. versus Bulimia Anxiety DisorderAnxiety Disorder Medical Condition (stomach)Medical Condition (stomach) Eating Disorder may be attention seeking because of Eating Disorder may be attention seeking because of

her sister’s extensive illnessher sister’s extensive illness

““Learning Issues”Learning Issues”

Learning issues will vary by the case Learning issues will vary by the case material. material.

Often the facilitators have to push for Often the facilitators have to push for greater awareness of “learning greater awareness of “learning issues.”issues.”

““Learning Issues”Learning Issues”

15 y.o white male 15 y.o white male – Are the dosing of medication normal?Are the dosing of medication normal?– What is Abilify and what is it used for? What is Abilify and what is it used for? – What are the implications of dysgraphia?What are the implications of dysgraphia?

13 year old with eating disorder13 year old with eating disorder – How is a growth chart used in the diagnosis of eating disorders How is a growth chart used in the diagnosis of eating disorders

in adolescents? in adolescents? – What is Total Anomalous Pulmonary Venous Rtn/Connection – What is Total Anomalous Pulmonary Venous Rtn/Connection –

the sisters congenital medical condition – and what would its the sisters congenital medical condition – and what would its implications be for her functioning and prognosis? implications be for her functioning and prognosis?

– What family system terms would be used to depict this family?What family system terms would be used to depict this family?

““Processing the Case”Processing the Case”

Reflections on “the case.”Reflections on “the case.” Reflections on one’s response to Reflections on one’s response to

“the case.”“the case.” Reflections on one’s skill in Reflections on one’s skill in

processing the “case.” processing the “case.”

Questions and Questions and DiscussionDiscussion