About a Boy – Case Study

1. About a Boy – Case Study Lynne Bell Willowgrove House

2. Willowgrove HouseTherapeutic Day Programme Holistic Model of Care Member of Community of Communities Recognised by: The Royal College of Psychiatrists, Centre for Quality Improvement www.therapeuticcommunities.org

3. Willowgrove House

4. Referrals Referrals from Department of Child & Family Psychiatry, St Johns Hospital Livingston Referral Criteria: Young Person 11 – 18 Years Unlikely to respond to outpatient intervention Commitment to participate in programme

5. Themes of Disorders - 2007

6. Evidence Based Formulation “Any formulation of anorexia nervosa and related eating disorders should aim to reflect the complex interplay over time of the major causative and maintaining factors” Childhood Onset Anorexia Nervosa and Related Eating Disorders Lask et al (1993)

7. Formulation? The individuals unique story of how the difficulties came about and why they have continued to experience them.

8. Evidence Based Formulation NICE CG009 Eating Disorders Core interventions in the treatment and management of anorexia nervosa, bulimia nervosa, and related eating disorders (National Clinical Practice Guideline Number CG9) developed by the National Collaborating Centre for Mental Health commissioned by the National Institute for Clinical Excellence

9. Evidence Based Formulation Eating Disorders in Scotland Summary of Recommendations for Management and Treatment NHS Quality Improvement Scotland 2006 NHS QIS

10. Case Study - Jon

11. Presenting Problem April 07 Jon 15 Years Increasing weight loss from time of reaching healthy weight, 4 months ago. Lost further 2 stones since then Eating approx once every 3-days Then inducing vomiting Marked anorexic cognitions Fear of fatness

12. Presenting Problem cont. April 07 Body image distortion Height 170cm, Weight 54Kg, BMI 18.7 Absent from school previous 4 weeks Attending alternative curriculum Not eligible for exams – due to non completion of course work Broke up girlfriend 3 weeks ago Mum also very concerned

13. Past Psychiatric Contact School refusal, due to bullying, 3 years ago

14. Formulation Contents Description of Difficulties Overview of Experiences Parental Influences Environmental Influences How Difficulties Developed Summary of Maintaining Factors Positive Factors Influencing Recovery

15. Home & Family Mum, brother & sister live at home No contact with father Shares room with brother Mum Jon 28 18 26 19 15 Living at Home

16. Social Situation Withdrawn from social contact with peers Isolating himself in room Previously large peer group – Skateboarding Smokes 10-12 Cigs per day No alcohol or drugs

17. Background Previously overweight Bullied at school Losing weight sensibly diet & exercise. Emergent anorexia from time of reaching ideal weight Not on medication cognitively impaired Muscle & bone pain At risk of developing bed sores

18. Working Diagnosis Anorexia nervosa & secondary depressed mood in 15yr old boy attending school.

19. Agreed Goal “To eat without having paranoid thoughts about others staring at me and, maintain my weight and feel better about my shape”. Jon Planned Action Individual Sessions Group timetable Weekly meetings with dietician Daily meal plan & meal time supervision Body image work Family Work

20. Recovery His mood was really bright and he shared that he “loves life and all is going well” He was attending open learning course at college. Celebrating 5mth relationship with his girlfriend.

21. Case Study - Bryan

22. Presenting Problem Jan 07 Bryan 15 Years Restricting type anorexia nervosa Onset Nov 05 More recent binging & bulimic episodes Body image distortion – fear of becoming fat, 4-5 weeks ago feeling faint, cold extremities, peripheral cyanosis

23. Past Psychiatric Contact None Medical History 1997 asthma 2003 shingles 2004 hay fever 2005 chest infection

24. Home & Family Lives at home with sister and parents. Mum Dad Bryan 11 15

25. Social Situation Social situation – several close friends tend to be older.

26. Background Vegetarian 2yrs ago Conflict with his parents about wanting to stay out with older friends Not eating with family since June 06 Episodes of bulimia followed by vomiting

27. Formulation Some developmental difficulties affecting him academically, eccentric presentation and very protective parents. Eating disorder could be seen as reaction to these difficulties, attempt to separate and individuate.

28. Goals “To eat normal healthy food intake without feeling guilty and worried thinking about it afterwards.” Bryan Short term aims – “To feel OK about weight and that being the thinnest person in the room is not always the happiest.” Bryan Planned Action – weekly individual meetings, fortnightly meeting with dietician, attend group programme, regular review with parents.

29. Recovery Positive about life and future Eating regular and responding to feelings of hunger Confident, Determined to get better Achieved exam results and going to art college Enjoying life

30. Developing Healthy Body Image, Guidelines Listen to Your Body Realistic About Your Size Exercise Enjoyable Way Expect Normal Changes in Weight/ Shape Work Towards Acceptance Work on Accepting others Discover Feelings What is Really Bothering You Ask for Support

31. Developing Healthy Body Image, Guidelines cont. Keep doing things you enjoy Replace Time Criticising with Positive Pursuits Hold Head High Accept Body is Changing Question Messages in Media Decide - Time Spent Pursuing the Perfect Body Image or Enjoying Family, Friends & Life