Pergamon J. Behav. Ther & Exp. Psychiat. Vol. 27, No. 1, pp. 57-65, 1996

Copyright © 1996 Elsevier Science Ltd Printed in Great Britain. All rights reserved

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THE USE OF CONTINGENCY M A N A G E M E N T IN THE TREATMENT OF A GERIATRIC NURSING HOME PATIENT

WITH PSYCHOGENIC VOMITING

DENISE M. SLOAN and J. SCOTT MIZES Case Western Reserve University, MetroHealth Campus

Summary - - A substantial percentage of nursing home residents evidence psychosocial and behavioral problems. However, surprisingly little is known about how effectively to treat geriatric patients with behavioral problems. The present study reports the behavioral treatment of a patient with psychogenic vomiting. The patient was successfully treated by changing the contingencies of her illness behavior and of behavior associated with rehabilitation goals. This indicates the importance of nursing home staff attending to the operants of illness behavior. Specifically, independent behavior should be rewarded by praise and attention and illness behavior should be ignored in terms of attention. Copyright © 1996 Elsevier Science Ltd

As the elderly population increases, the number of residents in geriatric settings also increases. A substantial percentage of nursing home residents evidence psychosocial and behavioral problems (Nash, Broome & Stone, 1987; Vaccaro, 1988; Prehn, 1982). These types of problems have also been associated with chronic illness behavior (Wooley, Blackwell & Winget, 1978). This behavior not only impedes rehabilitation goals (Fowler, Fordyce & Berni, 1969), but may also lead to further deterioration of physical health (Vandereycken & Meermann, 1988).

Despite the need for psychological interventions in geriatric settings (Lundervold & Lewin, 1995), surprisingly little is known about how to best treat geriatric patients with behavioral problems. Most studies of behavioral problems among geriatric patients have focused on problems associated with cognitive impairment (e.g. Lundervold & Jackson, 1992; Rossby, Beck & Heacock, 1992). However, other disorders, such as chronic illness behavior, also manifest psychosocial and behavioral problems that impede rehabilitation goals for geriatric patients. The literature on chronic illness behavior will be briefly reviewed, with an emphasis on psychogenic vomiting. Additionally, mechanisms for how this behavior may develop in geriatric settings will be discussed.

Chronic Illness Behavior Behavioral conceptualizations of chronic illness behavior suggest that it is a learned

behavior that is shaped by social contingencies. Disorders that have been associated with

Correspondence concerning this article should be addressed to J. Scott Mizes, MetroHealth Medical Center, 2500 MetroHealth Drive, Cleveland, OH 44109-1998, U.S.A.

57

58 DENISE M. SLOAN and J. SCOTT MIZES

chronic illness behavior include chronic vomiting, irritable bowel syndrome, headaches, seizure disorders, chronic pain, asthma and uncontrolled diabetes (Fordyce, 1988; Wooley et al., 1978).

For some patients, the illness role may initially be caused by an accident, injury or illness. However, the role is maintained through the predictable shaping process of social responses. The behavior is learned because it consistently elicits caretaking and attention. Fowler's colleagues (1969) have stated that the principles of operant conditioning are particularly important among the chronically ill due to the long-term care that presents patients with many opportunities for learning. The same opportunities for learning are present in geriatric long- term care settings.

Patients typically reside in nursing homes and skilled nursing facilities for extended periods of time. These types of facilities are most often caretaker oriented. Due to the large number of patients and limited availability of resources, minimal opportunity for patient independence is provided. As Fowler et al. (1969) has noted, the ways in which staff give attention to patients is powerful and predictive of patients' behavior. When there are limited resources the patients who make the most "noise" will often receive the most attention. In this way, chronic illness behavior is rewarded while positive behavior may be ignored.

Psychogenic Vomiting

Psychogenic vomiting is one type of behavior that has been suggested to be a chronic illness behavior (Wooley et al., 1978; Haggerty & Golden, 1982). Psychogenic vomiting is defined as vomiting without any obvious organic pathology, resulting from psychological mechanisms (Hill, 1968; Leibovich, 1973). It differs from self-induced vomiting, as seen in bulimia and anorexia, in that it is spontaneous, effortless and involuntary (Fullerton, Neff & Getto, 1992).

The concept of psychogenic vomiting as a learned form of behavior was first posited by Hill (1968) and more recently by Rosenthal, Webb and Wruble (1980). According to Rosenthal et al., once vomiting is experienced during organic or functional disease, it becomes reinforced by short-term benefits and becomes a habit.

Several main characteristics of the psychogenic vomiting syndrome have been described. There is typically a history of vomiting over a matter of months or many days (Morgan, 1985; Muraoka, Mine, Matsumoto, Nakai & Nakagawa, 1990) and it is more common in women than men (5:1; Morgan, 1985). Rosenthal and his colleagues (1980) state that the typical presentation is characterized by retention of good appetite, little weight loss and vomiting that usually follows the ingestion of food. On the contrary, Hill (1968) reported that the psychogenic vomiting patients that he studied displayed chronic and disabling symptoms. He found that the majority of the patients suffered nausea and significant weight loss in association with vomiting. Consistent with Rosenthal et al., Hill found that the vomiting was worse at meal times. Based on prior clinical descriptions of the syndrome, it appears that psychogenic vomiting may have a wide range of severity levels, ranging from short-term minor intermittent illness to chronic and disabling symptoms.

While there have been a number of descriptions of psychogenic vomiting, guidelines for the treatment of psychogenic vomiting have not been established. Moreover, to the best of our knowledge, there have been no case descriptions of the treatment of the chronic illness behavior of psychogenic vomiting in a nursing home setting. The present study reports the behavioral treatment of a sixty-year-old woman with psychogenic vomiting in a skilled nursing facility. The purpose of the study was to examine the efficacy of contingent behavior therapy

Contingency Management 59

using an A-B design in a nursing home setting. Single subject design methodology is a frequently used approach for assessing the treatment effects of rare chronic illness behavior (e.g. Mizes, 1985; Stravynski, 1983).

Method

Patient Information and Background

The patient, J, was a 60-year-old, single, Caucasian woman who was referred to the Eating Disorders Clinic by the staff at the skilled nursing facility where she was a patient. She was referred to the Eating Disorders Clinic to rule out an eating disorder because she had substantially reduced eating during the previous ten months, was vomiting on a regular basis, and had lost 49 pounds since her admission. No organic origin was found for her vomiting behavior and apparent inability to orally ingest food. She had also had an unsuccessful trial on antidepressant medication prescribed by a consulting psychiatrist.

J was at the skilled nursing facility to rehabilitate from a flesh eating streptococcal infection of her lower right and left legs. While the disease had been successfully treated, J had not made any progress in her rehabilitation goals which were to become less caretaker dependent by becoming ambulatory. Her specific goals were to propel herself in a wheelchair and ultimately walk with the assistance of a walker. At the time of the referral J had been at the skilled nursing facility for ten months. She was dependent on tube feeding for her daily calorie intake, was incontinent, was not engaging in ward activities, and had isolated herself in her room throughout the entire day where she would lie in bed and watch television.

J began spontaneously vomiting shortly after her admission to the skilled nursing facility. The initiating condition for the vomiting was a combination of depression and anxiety. However, once initiated, J's vomiting behavior was maintained by the attention and care that she consistently received from the nursing staff. Additionally, she did not assist in cleaning herself after a vomiting episode. Due to her vomiting behavior, J was also able to frequently excuse herself from activities that she did not want to attend, such as physical therapy and ward activities. Progress towards rehabilitation goals did not appear to be reinforced by the nursing staff as consistently and positively as J's illness behavior.

Treatment

After the initial evaluation at the Eating Disorders Clinic, J was diagnosed as having major depressive episode, generalized anxiety disorder, and conversion disorder with motor symptoms. No evidence of an eating disorder was found. At J 's initial evaluation she completed the Minnesota Multiphasic Personality Inventory, version 2 (MMPI-2; Hathaway & McKinley, 1989) and the Beck Depression Inventory (BDI; Beck, Ward, Mendelson, Mock & Erbaugh, 1961), on which she obtained a score of 47. Table 1 presents J's MMPI-2 pre and posttreatment t-scores for each scale. As can be seen in Table 1, several of the scales were clinically elevated at pretreatment, including hysteria, depression and hypochondriasis.

Treatment focused on contingent reinforcement for decreased vomiting behavior and increased oral food intake. Visual imagery to reduce feelings of anxiety and nausea was also included in the treatment. A contingency contract was established with the patient in which she would eat her entire meal without vomiting in order to receive the privilege of watching

60 DENISE M. SLOAN and J. SCOTT MIZES

Table 1

Pre- and post-treatment MMPI-2 t-scores

Scale Pretreatment score Posttreatment score

L 57 59 F 65* 48 K 56 56 1 82* 65* 2 92* 66* 3 75* 58 4 55 43 5 52 52 6 59 42 7 83* 55 8 75* 42 9 49 39 0 77* 69*

*Clinically elevated.

television until her next meal was delivered. Although the daily calorie limit of 1200 was determined by the hospital nutritionist, J was able to choose her meal items from a list of options. Nursing staff were instructed to ignore the patient when she vomited and allow her to clean herself, unassisted, following vomiting episodes. They were also instructed to praise and give attention to the patient when she successfully ate a meal without vomiting.

After the patient agreed to the contract, a three-day baseline phase followed. On the fourth day, the contingency phase was implemented. Figure 1 presents the frequency of vomiting episodes per day and Figure 2 presents the number of meals consumed per day. As can be seen in Figures 1 and 2, the patient did not consume any meals and vomited with every meal during the baseline phase. During the contingency phase, the patient was able to successfully eat her first two meals without vomiting. She then experienced an extinction burst at the third meal of the contingency phase. Before a target behavior is extinguished the behavior may actually increase in frequency or intensity. As in the present case, the extinction burst is most likely to occur at the beginning of treatment (Karoly & Harris, 1986). The patient ate only a portion of her third meal and vomited. In consequence of this, her television was unplugged according to the mutually agreed upon contract. The patient became irate and vomited an additional three times. But on the next day she was no longer upset and proceeded to eat her meals without vomiting.

By the third day of the contingency phase, the patient reported no nausea at meal times or at all other times during the day. The patient reported that she had an appetite, looked forward to meals, and felt physically better than she had in many months. Her affect also significantly changed as she became more energetic and less depressed. The patient reported that she used visual imagery to reduce her feelings of nausea for the first two days of the contract, but she did not use the imagery thereafter as she no longer experienced feelings of nausea. She also stated that due to her success with eating, she was looking forward to trying new things to see what else she might be able to achieve. The patient became very active in ward activities and began making substantial progress in both physical and occupational therapy.

Figure 3 illustrates the patient's progress in physical therapy as indexed by feet walked with

C o n t i n g e n c y M a n a g e m e n t 61

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walker per week, beginning four weeks prior to the contingency phase. As can be seen in Figure 3, the patient began walking with a walker in physical therapy only after the contingency phase began and continued to progress during the weeks that followed. It is important to note that the patient had never walked with a walker during the previous ten months of her hospitalization. In occupational therapy, the patient began working on areas that would increase her independence, such as going from the bed to the toilet. She also learned to stand on her own to use the toilet. She ceased to be incontinent.

o o

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62

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DENISE M. SLOAN and J. SCOTT MIZES

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With each new success the patient was praised by staff members and received significant attention for her improvements. The contingency phase ended after two weeks because she was no longer vomiting, not watching as much television throughout the day, and was eating all of her meals. A week later she was weighed, and had gained eight pounds.

The BDI and the MMPI-2 were readministered four weeks after the contingency phase was implemented. The patient obtained a score of 6 on the BDI posttreatment testing. This was a substantial decrease from the score of 47 that the patient obtained at pretreatment testing. As seen in Table 1, the scales on the MMPI-2 that had been clinically elevated at pretreatment had substantially decreased at postreatment testing.

To ensure that the positive behavior that the patient was exhibiting would generalize outside the skilled nursing facility, she had her last three sessions at the Eating Disorders Clinic which is located at another hospital. To continue fostering the patient's independence, she came to these sessions unaccompanied by staff members from the skilled nursing facility. She reported having had no feelings of anxiety attending therapy sessions alone outside the hospital. In fact, she enjoyed having the opportunity to go outside.

Due to the patient's significant progress in her rehabilitation goals, she was discharged to an assisted living facility seven weeks after the contingency phase was implemented. Before her discharge, several relapse prevention measures were established to enhance the psychosocial quality of her life and to foster independence. First, the patient became a volunteer in the recreational activities department of the hospital. She also became a member of a local senior citizen center, which provided transportation to and from the patient's new residence. Finally, she obtained a pass for the Community Responsive Transit bus system of Cleveland, which provides transportation at low cost to elderly and disabled individuals.

Follow-up

A follow-up session was held four weeks after psychotherapy sessions were terminated and

Contingency Management 63

two weeks after the patient was discharged to an assisted living facility. Upon discharge, the patient reported no feelings of anxiety or depression. She continued to eat on a regular basis and did not experience any relapse in feelings of nausea. The patient kept active with her volunteer activities, physical therapy appointments and her involvement with a senior center that was near her new residence. Staff members at the assisted living facility reported that the patient was seldom secluded to her room and spent most of her time in the community room socializing with the other residents of the facility.

Discussion

The present study reports the treatment of a patient in a nursing home with psychogenic vomiting. The patient was unable to achieve rehabilitation goals as a result of her psychogenic vomiting during the prior ten months in the skilled nursing unit. Once a contingency contract was established, in which the patient was ignored for her illness behavior and rewarded for independent behavior, her vomiting behavior was extinguished and she made progress towards rehabilitation goals.

Although the chronic illness behavior described in the present study may be unusual, the general problem of chronic illness behavior among residents of nursing home settings is not. Geriatric patients who are most at risk for developing chronic illness behavior may be individuals who have limited social contacts.

The patient had had limited social supports before her hospitalization. She had relied on her parents, primarily her mother, and her job for social contacts. When her mother died and she quit her job of 35 years, she had minimal contact with other people. She spent most of her time isolated in her apartment. She reported that it was difficult for her to meet new people. Her hospitalization at the skilled nursing facility provided her with new social contacts. For this reason, she was not motivated to be discharged from the skilled nursing facility. Once she learned that she could maintain contact with staff members through independent behavior, with support much more positive than before, she ceased to rely on chronic illness behavior to obtain social support and her psychogenic vomiting behavior was extinguished.

If psychological intervention had been implemented sooner, the nursing home where she was a patient and Medicaid could have avoided substantial financial cost. The cost of a day stay in the nursing home was $295 plus ancillary costs. When she was a Medicaid patient, Medicaid only reimbursed the nursing home $161 per day. Had psychological intervention occurred as soon as J 's illness behavior was exhibited, she most likely would have had a total nursing home stay of approximately three months. Instead she spent over 13 months in the nursing home. If immediate psychological intervention has been sought, the cost savings, not including ancillary costs at the nursing home would have been $40,200, and the cost savings to Medicaid would have been $48,300. The Eating Disorders Clinic was compensated by Medicaid $456 for the 12 sessions of treatment. Even at the usual $90 cost of a psychotherapy session in the city of Cleveland, the total cost would still have been substantially less than the cost of the nursing home.

The present case study employed an A-B single-case design to study the effects of contingent reinforcement with a geriatric patient exhibiting psychogenic vomiting. An A-B design is superior to uncontrolled case studies because it directly measures a target behavior and the effects of the introduction of treatment can be directly compared to the measured baseline rates of the target behavior. However, A-B single-case designs are methodologically limited in that they represent a correlational design. Therefore, the changes in the target

64 DENISE M. SLOAN and J. SCOTT MIZES

behavior cannot be definitively attributable to the introduction of the treatment. An A-B-A design (where the target behavior is measured at baseline, treatment, and treatment removed) would have allowed us to attribute the changes in Js target behavior unequivocally to the treatment.

The present case study did not employ an A-B-A design for several reasons. First, it would have been unethical to remove an apparently effective treatment from a patient who had suffered a high degree of deterioration. Second, because the patient's vomiting behavior was quickly extinguished and she no longer desired to watch television to the extent she had previously done, we would have been unable to reverse the treatment. Although we cannot unequivocally state that changes in the patient's behavior were directly a result of the treatment, the progress in the patient's rehabilitation and her change in behavior following behavioral treatment was dramatic.

The present study demonstrates the need to change the operants that exist within a nursing home setting for patients who exhibit chronic illness behavior. Nursing home settings provide many opportunities to learn illness behavior as a way to obtain attention and care taking. Independent patient behavior is often unrewarded in such settings, most likely as a result of the shortage of nursing staff and high demand of patients seeds. Since behavior is a function of its consequences, behavior that receives attention from nursing staff is likely to be repeated, whereas behavior that is ignored or unrewarded is unlikely to be repeated. Therefore, staff members of nursing home settings should consider the operants that affect patients displaying chronic illness behavior. Staff time and resources may be utilized more efficiently by staff members attending to and praising independent behavior and attending to dependent behavior minimally, if at all. The present case also illustrates the importance of early psychological consultation and intervention for nursing home patients.

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Contingency Management 65

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