La formulazione del caso clinico. GARN - Bologna 7 Maggio 2016

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Vittorio Palla
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1 La formulazione del caso clinico 1 R O M A N A S C H U M A N N E L A B O R A Z I O N E D E L G R U P P O N E T W O R K E R / M E B O Z Z A D E L L A C A R T E L L A C L I N I C A S I S D C A

2 FORMULAZIONE DEL CASO 2 DATI ANAGRAFICI Reference: - Eells, T. D., Kendjelic, E. M., & Lucas, C. P. (1998). RICHIESTA DEL PAZIENTE What's in a case formulation?: development and use of a content coding manual. The Journal of COMPOSIZIONE Psychotherapy Practice and Research, 7(2), DELLA Haynes, S. N., & Williams, A. E. (2003). FAMIGLIA Case GENOGRAMMA FAMILIARE formulation and design of behavioral treatment ANAMNESI MEDICO INTERNISTICO NUTRIZIONALE ANAMNESI FISIOLOGICA ANAMNESI PATOLOGICA programs: Matching treatment mechanisms to causal variables for behavior problems. European Journal of Psychological Assessment, 19(3), Kinderman, P. (2005). A psychological model of mental disorder. Harvard review of psychiatry, ANAMNESI TRATTAMENTI PREGRESSI 13(4), Levenson, H., & Strupp, H. H. (1997). Cyclical maladaptive patterns: Case formulation in timelimited dynamic psychotherapy.

FAMIGLIA Case GENOGRAMMA FAMILIARE formulation and design of behavioral treatment ANAMNESI MEDICO INTERNISTICO NUTRIZIONALE ANAMNESI FISIOLOGICA ANAMNESI PATOLOGICA programs: Matching treatment

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5 FORMULAZIONE DEL CASO 5 DESCRIZIONE DEL PROBLEMA (sintomi descritti dal paziente, aspetti cognitivi, comportamentali, emotivi, problemi interpersonali, problemi lavorativi-scolastici) STORIA DEL PROBLEMA Esordio Evento scatenante Meccanismi di mantenimento Vantaggi secondari Rerefence: Haynes, S. N., & Williams, A. E. (2003). Case formulation and design of behavioral treatment programs: Matching treatment mechanisms to causal variables for behavior problems. European Journal of Psychological Assessment, 19(3), 164. Kendjelic, E. M., & Eells, T. D. (2007). Generic psychotherapy case formulation training improves formulation quality. Psychotherapy: Theory, Research, Practice, Training, 44(1), 66. Kinderman, P. (2005). A psychological - model of mental disorder. Harvard review of psychiatry, 13(4), Poerio, V. (2014). Il piano di trattamento nelle psicoterapie ad impianto cognitivo. Assessment, concettualizzazione e pianificazione del caso clinico: Assessment, concettualizzazione e pianificazione del caso clinico. FrancoAngeli.

Case formulation and design of behavioral treatment programs: Matching treatment mechanisms to causal variables for behavior problems. European Journal of Psychological Assessment, 19(3), 164.

6 FORMULAZIONE DEL CASO 6 DIAGNOSI CATEGORIALE (DSM-5) (gravità) (SEED in prova) DIAGNOSI DIFFERENZIALE (Comorbilità e sequenzialità dei disturbi) DIAGNOSI ESPLICATIVA Ipotesi sulla costruzione-mantenimento del sintomo Stile relazionale del paziente Analisi funzionale Reference: - Eells, T. D., Kendjelic, E. M., & Lucas, C. P. (1998). What's in a case formulation?: development and use of a content coding manual. The Journal of Psychotherapy Practice and Research, 7(2), Haynes, S. N., & Williams, A. E. (2003). Case formulation and design of behavioral treatment programs: Matching treatment mechanisms to causal variables for behavior problems. European Journal of Psychological Assessment, 19(3), Levenson, H., & Strupp, H. H. (1997). Cyclical maladaptive patterns: Case formulation in time-limited dynamic psychotherapy. - Poerio, V. (2014). Il piano di trattamento nelle psicoterapie ad impianto cognitivo. Assessment, concettualizzazione e pianificazione del caso clinico: Assessment, concettualizzazione e pianificazione del caso clinico. FrancoAngeli.

: development and use of a content coding manual. The Journal of Psychotherapy Practice and Research, 7(2), 144. - Haynes, S. N., & Williams, A. E. (2003).

7 FORMULAZIONE DEL CASO 7 BREVE DESCRIZIONE BIOGRAFICA E DELLO SVILUPPO PSICO- SOCIALE Descrizioni dell ambiente nell infanzia/adolescenza, relazione con i genitori e/o figure di riferimento) Esperienze significative durante le diverse fasi evolutive Rapporti amicali ed affettivi

relazione con i genitori e/o figure di riferimento) Esperienze

8 FORMULAZIONE DEL CASO PROGETTO TERAPEUTICO E OBIET TIVI DELLA TERAPIA 8 Definizione del livello di cura (Ambulatoriale, Terapie intensiva giornaliera, Ricovero riabilitativo, Day Hospital, Ricovero ospedaliero acuto) Definizione del setting (individuale, di gruppo) IL PROGETTO TERAPEUTICO INTEGRATO Motivazione, consenso e condivisione con paziente e famiglia, gradualità e sequenzialità nella integrazione delle terapie ASPETTI PROGNOSTICI SULL ANDAMENTO DELLA TERAPIA Valutazione delle competenze metacognitive, motivazione al cambiamento, valutazione delle caratteristiche relazionali, competenze di resilienza, comorbilità, durata, multitrattamento, multiimpulsività, aspetti suicidari, apoggio dell ambiente familiare DURATA DEL TRATTAMENTO Asssessment, alleanza terapeutica e condivisione del progetto terapeutico, terapia anti-ansia, traumaterapia, trattamento delle comorbilità, costruzione di risorse e competenze, prevenzione delle ricadute, follow-up Reference: Eells, T. D., Kendjelic, E. M., & Lucas, C. P. (1998). What's in a case formulation?: development and use of a content coding manual. The Journal of Psychotherapy Practice and Research, 7(2), 144. Levenson, H., & Strupp, H. H. (1997). Cyclical maladaptive patterns: Case formulation in time-limited dynamic psychotherapy. Kinderman, P. (2005). A psychological model of mental disorder. Harvard review of psychiatry, 13(4), Poerio, V. (2014). Il piano di trattamento nelle psicoterapie ad impianto cognitivo. Assessment, concettualizzazione e pianificazione del caso clinico: Assessment, concettualizzazione e pianificazione del caso clinico. FrancoAngeli.

integrazione delle terapie ASPETTI PROGNOSTICI SULL ANDAMENTO DELLA TERAPIA Valutazione delle competenze metacognitive, motivazione al cambiamento, valutazione delle caratteristiche relazionali,

9 CRITERI SEED CRITERI per Severe and Enduring Anorexia Nervosa (SEED-AN): Bamford and Mountford (2012) suggest the following: 1. consistently ill for 10 years or more 2. experience of at least one recognized therapeutic treatment 3. severity of impairment across a number of life domains 4. demonstrate low motivation for recovery Hay, Touyz, and Sud (2012) in their review chose a minimum of 3 years Touyz et al. (2013) in their treatment study chose at least 7 years. However, in a Delphi study of professionals (Tierney & Fox, 2009), no consensus on duration of illness for the definition of SEED was reached, and Bamford and Sly (2010) in a quantitative study found that duration of illness did not predict quality of life in AN. PROPOSTA 9 COSTRUZIONE DI UN DATABSE

demonstrate low motivation for recovery Hay, Touyz, and Sud (2012) in their review chose a minimum of 3 years Touyz et al. (2013) in their treatment study chose at least 7 years.

10 Trattamento SEED 10 Currently, there is no recommended first-line therapy for adults presenting with AN in the later stages of illness The limited evidence available for patients in the severe, enduring stage of illness suggests that remission rates are modest and treatment acceptability is poor. Treatment drop-out can be high from outpatient treatment and 26 41% of patients need additional in- or daypatient care, because of either a failure-to-improve or a deterioration of symptoms. A focus on more of the psychosocial consequences of the illness may be of benefit for this stage delivered either individually or through the family. Further exploration of treatment approaches for people who do not respond or who do not receive a timely first line effective intervention is needed. Many treatments for eating disorders have been adapted from those used to treat other conditions. It is possible that a more targeted approach to key eating disorder symptoms may improve outcomes. Translating from experimental medicine into clinical practice involves a variety of steps. The first is to build an accurate clinical profile of the various symptoms and model the underpinning psychopathology. The next stage is to consider possible techniques to foster change and to modify these dysfunctional systems. If we apply this construct to eating disorders then we are probably at the drawing board stage of model building especially for those in the severe enduring phase of illness. Conclusion: In line with a consideration of the staging categorisation of people with eating disorders it might seem necessary to develop a form of stepped care protocol for patients with eating disorders. In the case of people who are resistant to standard first line therapy it may be beneficial to use treatments that directly target some of the dysregulated circuits that maintain the disorder. These may circumvent the need to work only through top down processes, which are disabled by the neuroprogressive changes that ingrain in the habits and fears that maintain the disorder. This is an area of rapid growth that may offer hope to people at the severe enduing stage of the disorder. Reference: J. Treasure et al. (2015):

Treatment drop-out can be high from outpatient treatment and 26 41% of patients need additional in- or daypatient care, because of either a failure-to-improve or a deterioration of symptoms.

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