Case Study – Celine
Laurie Cyr-Martel
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Patient
Presenting problem: Celine is a 25 year old female who presented to the emergency department (E.D.) with increased abdominal pain over the last 2 weeks. Patient recently completed chemotherapy and cancer treatment for intestinal cancer. Celine has been under increased stress due to her living situation and is concerned that her cancer has returned. She reports the pain is different than when she was initially diagnosed. She had an appointment with her oncologist on Monday, but by Friday night the pain was excruciating and she presented to the ED on Saturday morning.
Background and demographics: Celine was born in a suburb of Maine, never knowing her biological father, was raised (a term she uses loosely), by her mother and resided with her mother and biological brother two years her senior. The patient reports most of her life, her mother was an addict. According to Celine, from an early age – which she reports as 5-10 years of age, she remembers her mother’s drug of choice as alcohol. When her maternal grandparents visited, the addiction was hidden. While Celine was in Junior high and high school, her mother’s drug of choice was cocaine. Celine reports her mother would make her steal either food or money. Celine was told that if she was caught, “nothing bad would happen.” Celine was fearful if she told anyone of the environment, the state would make her live in foster care. From ages 12-15, Celine found her mother clinically dead twice, Celine called 911 and her mother was revived. Both times, the mother entered rehab with the intention of becoming sober and clean. In those times Celine stayed with her maternal grandparents. Her mother would “get clean” and Celine and her brother would return home. Celine’s brother experienced a traumatic brain injury his senior year in high school while riding an All-Terrain Vehicle (ATC). His home care fell to Celine. It was at this time Celine, who had just turned 16, was diagnosed with intestinal cancer. According to Celine, while she was going through Chemotherapy, her mother would steal her pain meds, leaving Celine to endure the pain. She was deemed in remission at the age of 19 after a 3 year battle, the cancer returned last year at age 24. Celine completed high school as an above average student, but was unable to attend college due to increased anxiety. At the age of 21, Celine who was still living with her mother and acting as care taker, found her mother unconscious and called emergency services. Her mother was unable to be revived. Celine contacted the State at this time, to request help with her brother. According to Celine, the state was surprised to learn that no one had previously intervened. Celine moved into her own apartment and is currently on disability, due to her medical and anxiety concerns. Her brother lives in a group home setting, whom she visits seldom. Celine reports that in the last six months she has noticed increased anger and is working with her therapist to determine the reasons and rationale.
The two scales used to determine intervention and resources for both the anxiety and the patients history of intestinal cancer were the GAD-7 (Lowe, Decker, Muller, Brahler, Schellberg, Herzog, & Herzberg, 2008; Spitzer, Kroenke, Williams, & Lowe, 2006) and the Cancer Behavior Inventory (CBI-B) (Heitzmann, Merluzzi, Jean-Pierre, Roscoe, Kirsh, & Passik, 2011; Merluzzi, Nairn, Hedge, Martinez Sanchez, & Dunn 2001; Merluzzi, & Martinez Sanchez, 1997).
Measurements
CBI-B:The CBI-B is a shorter version of a previously well-established measure of the Cancer Behavior Inventory – Long Version (Heitzmann, Merluzzi, Jean-Pierre, Roscoe & Kirsh 2011). The long version is a 33-item tool, developed to measure how well an individual copes with cancer. The long and short version of the CBI, measure items on a nine point scale from “not at all confident” to “totally confident.” The internal consistency in the longer version of 33 items produced a co-efficient of 0.94 and the test-retest for the 33 item CBI was 0.74 (Merluzzi, Nairn, Hedge, Martinez Sanchez, & Dunn 2001; Merluzzi, & Martinez Sanchez, 1997). As my interaction with this patient was limited due to the emergency department location, the patient agreed to participate using the shorter version, 12 item CBI-B. The Cronbach co-efficient of the 12 item version, indicated an internal consistency of .84, attained in three different samples (Heitzmann, Merluzzi, Jean-Pierre, Roscoe, & Kirsh 2011). Thus, the results in using this assessment indicate acceptable reliability to the degree to which the patient believes she is able to cope and maintain her health during her experience with cancer. The quality of life measures were also positively correlated with the negative correlations or depression and the impact of sickness, demonstrating the validity of the CBI-B (Heitzmann, Merluzzi, Jean-Pierre, Roscoe, & Kirsh 2011). Patients who believe they are able to cope with the illness are more apt to connect with the resources to face the multiple challenges of the disease. .
GAD-7: Reviewing validity studies for the GAD-7, resulted in agreement this measurement tool is appropriate and validated for use in primary care (Spitzer, Kroenke, Williams,& Lowe, 2006), those in a hospital program, (Kertz, Bigda-Peyton, & Bjorgvinsson. 2013), and the general population (Lowe, Decker, Muller, Brahler, Schellberg, Herzog, & Herzberg, 2008). Spitzer et al., (2008) used a large sample size (2982), and took into account ethnicities, age, education, and relationship status. The diversity and sample size allowed for various correlations, producing a Cronbach which resulted in a score of 0.92 indicating an excellent internal consistency. Within the general population, there is evidence to support the validity and the reliability of the GAD-7. Lowe et al., (2008) used a sample of 5,032 participants. The researchers assessed the construct validity by comparing scores of those diagnosed with general anxiety disorder in primary care settings, to the scores of those diagnosed with GAD in the general population. The internal consistency resulted in an acceptable 0.89. Although a smaller sample size of 232 was selected from a partial hospital program to measure the validity of the GAD-7 (Kertz, Bigda-Peyton, & Bjorgvinsson 2013), the study concluded that due to the brevity, easy administration, that the GAD-7 had strong construct validity. The associations with self-esteem, depression, resilience and how satisfied a patient is with their life, demonstrated good reliability and construct validity within the GAD-7 in all three studies (Lowe et al., 2008; Spitzer et al., 2006; Kertz, Bigda-Peyton, & Bjorgvinsson 2013).
Administration:
The CBI-B and the GAD-7 were administered twice; upon the initial assessment and the third contact. (The second contact was by phone to ascertain the results of her appointment with her oncologist. The patient advised that the results of her blood work was “looking positive.”)
When initially administered, CBI-B score was 64. (Figure 1) The scores indicating the patient was able to maintain her abilities when confronting her disease, but not yet at a point where confidence was paramount. As the CBI-B was administered only twice, a wide variation in scores was not expected.
The third contact, the patient agreed to meet in the conference room of the emergency department. I asked if this would be a hardship as her grandmother would be traveling three hours. The patient advised she had an appointment with her oncologist, and she wanted me to explain the measurement tools to her grandmother. Results of the second administration of the CBI-B was 91; (Figure II) indicating an increase in self efficacy within two weeks.
The initial score from the GAD-7 was 19 (Figure III) indicating severe anxiety. The patient is currently being treated for her anxiety, so the elevated score was not a surprise to this practitioner. However, the patient was concerned as she had been working on decreasing her anxiety with her current therapist.
The patient was hesitant to take the GAD-7 the second time as she was apprehensive it might not change. Upon taking the second test, (Figure IV) the patients score actually resulted in positive news for Celine decreasing by 5 points.
Scores: The patient attributed the positive change in the scores for both the GAD -7 and the CBI-B as a result of relocation to her maternal grandparent’s home on the coast of Maine where she was close to the ocean able to use her photography and find “peace in her heart.” As evident in the CBI-B, relaxation, coping, consolation, and having some-one whom she could share her concerns and feelings. These scores had increased. The patient advises that she has been able to use the breathing techniques when she begins to feel overwhelmed.
The decrease in the anxiety scores may also be correlated to the relocation, support systems, access to hobbies. Although, the patient’s score still borders on severe, her future outlook presents as positive when speaking of her living situation. Celine admits to worry about her cancer, but believes she will continue to improve. Celine’s passion has always been with the artistic realm. Her grandparents have become involved in Celine’s life. They live three hours away on the coast of Maine. Celine finds solace at the ocean. The Grandparents purchased a camera for Celine two years prior. She currently takes photographs of nature, her grandfather makes the frames for the pictures and they are sold at fairs. Celine advises a few of her pictures have been placed in the reception area of a local hospital.
Discussion: Both measurement tools used with this patient were of great validity in the emergency department setting. As there is not always a chance to follow up with patients, I was fortunate to gather information not just from the tool itself, but the patient’s reactions, participation, and discussion when using the measurement tools. Follow up with her therapist would be paramount to continue addressing the anxiety. The patient advises she will be attempting to locate another therapist closer to her grandmother. We were able to locate several therapists in a nearby town. The young woman’s resiliency may be the result of the hardships already endured at a young age. According to Merluzzi & Martinez Sanchez (1997), social supports, whether perceived or actual are positively correlated to self-efficacy. {The second and final meeting resulted in opening a dialogue between the patient and her grandmother}. Celine began an on line class for photography and is hopeful to create her own business.
The two chosen measurements correlated well together. The ability to regulate ones affect, adapt to the negatively of cancer, and express those thoughts, the more positive the outcome (Merluzzi, et al., 2001). If the therapist can continue to address the anxiety in terms of self-efficacy, it is possible that Celine will continue to increase her good health.
