The Medical Model in Psychiatry and Social Science Discussion
First, make sure that your answer is backed up by the readings, videos, and lectures assigned in the course. You don’t need to use exact APA format for an answer- I will accept any way of communicating that you’re citing sources that is clear. This includes both mentioning the source in an informal way (e.g., “Dr. Ghaemi stated that…”) or using the APA citation without citing the reference in a list (e.g., writing, “(Lacasse, 2015).” I allow this expeditious way of citing because I am deeply familiar with the sources that you’ve been exposed to and the most important thing for this test is your grasp of the ideas, not formatting. Referencing multiple sources when appropriate is not required but does demonstrate that you’ve done the reading.
2. Write an adequately long answer but be succinct. Being able to summarize what you’ve learned is a sign that you’ve mastered the material. There is no set answer length for each question, but they can all be answered in a paragraph- sometimes short, sometimes a bit longer. But, in general, these questions can be answered in 3-10 sentences.
3. Make sure that you aren’t giving an answer that is flatly contradicted by the assigned course materials.
4. Make sure that you’re using psychiatric vocabulary correctly. For instance, probably the most common error on this test over the years is a misunderstanding of the term “reliability” which then leads to points being subtracted when grading the overall answer.
5. Edit your answers carefully. If your answer isn’t clear, you will lose points. Grammarly and a second read-over are both helpful in this regard. This is a test, not a conversation, and so I have to grade what you write.
1. The medical model is the reigning paradigm in mental health prevention, diagnosis and treatment. Describe this model in as much detail as possible.
2. The medical model is the reigning paradigm in mental health prevention, diagnosis and treatment.
What are the most compelling falsifications of this model, e.g., what evidence exists that this model, as commonly communicated, is flawed or incorrect?
3. Allen Frances discussed the issue of diagnostic inflation (similar to over-diagnosis) that took place with DSM-IV. What diagnostic epidemics resulted from DSM-IV, and why?
4. Imagine you are talking with Dr. Kimmy Schmidt, a psychologist who has just emerged from a bunker. Prior to entering the bunker, Dr. Schmidt used DSM-IV-TR religiously. Describe the DSM-5, and any attendant controversies/debates that emerged around the released of DSM-5. Do not discuss Major Depressive Disorder as this is asked about below.
Use the word reliability in your answer.
5. The DSM-5 diagnostic process purports to avoid diagnosing clients who are simply socially deviant, weird, or different.
Explain how the DSM-5 process formally addresses this.
6. The DSM-5 formulation of Major Depressive Disorder has been controversial. Describe the reasons for the concerns and the possible negative consequences of the new formulation.
7. Research suggests that ‘serotonin deficiency’ and ‘chemical imbalance’ are common etiological explanations provided to depressed clients. Are such statements (A) correct, (B) based on scientific evidence, and if so, (C) what evidence?
If such statements aren’t true, why do you think the continue to be used by clinicians in 2020? Use information from the assigned readings to answer.
8. Pretend you are explaining mood disorders to someone that knows nothing about the topic. What’s the difference between Major Depressive Disorder, Bipolar I Disorder, and Bipolar II Disorder?
9. Name 5 clinical terms used within the diagnosis of mood disorders such as depression and bipolar (e.g., anhedonia). Define each.
10. How does one distinguish Bipolar I disorder from Schizoaffective Disorder, Bipolar Type?
11. Many of you wrote in the discussion board that Bipolar Disorder, particularly Bipolar Disorder II, is both over-diagnosed and under-diagnosed.
It is true that some clients who should be diagnosed with BP II are not (under-diagnosis) and that some clients who shouldn’t be diagnosed with BP II are diagnosed that way (over-diagnosis).
But, on a national level (e.g., the entire U.S.), it is impossible for both over-diagnosis and under-diagnosis to exist in the aggregate. Overall, either the disorder is under-diagnosed or over-diagnosed.
Based on research, data, and argumentation, which is it, and why?
12. Diagnose the vignette below. Follow the 6-step process that we’ve discussed throughout the semester. Explain your reasoning carefully so that even if you miss the exact diagnosis, you still receive some credit.
A hospital-based psychiatric consultation-liaison service was called to assess possible depression in Rebecca Ehrlich, a 24-year-old woman who had been hospitalized 2 days earlier for severe abdominal pain. She had been admitted through the emergency room for the latest flare-up of her underlying Crohns disease. The consultation was called after the nurses became concerned that she was sad and lonely and was having a difficult time adjusting to her medical condition.
Ms. Ehrlich was interviewed by the medical student on the psychiatry service. The patient indicated that the pain was excruciating and that she was neither sad nor lonely but was simply visiting from out of town, so no one knew she was even in the hospital. She told the medical student that her only previous therapy had been in college, when she went to student health services to get help for anxiety about test taking and her career choice. She had successfully completed a short course of cognitive-behavioral therapy, and the anxiety had not reappeared. She denied any other psychiatric history and had never taken psychiatric medication. In college, she studied psychology and worked part-time as a hospital orderly. Ms. Ehrlich had considered a career in medicine or nursing and asked the student how he had decided to go to medical school.
Ms. Ehrlich said that she had previously worked regularly and had quite a few friends but that the recurrent abdominal pain had wrecked her social life and her job prospects. She had lost a job the year before because of absenteeism and had missed several job interviews due to her Crohns flares. She had dated as a teenager but had been single since college. These things were not the end of the world, but how would you feel? As a member of an online bowel disorders support group, Ms. Ehrlich e-mailed other members on a daily basis. She added that the only person in the family who got her was an aunt who also had Crohns disease.
The primary medical team was having difficulty obtaining collateral information from previous physicians, but the medical student was able to contact Ms. Ehrlichs mother. She did not know the exact names or phone numbers of her daughters medical providers but did recall some of the hospitals and could recall, approximately, some of the physicians names. She added that her daughter had not wanted her to be involved in her care and had not told her she was out of town, much less that she was in the hospital. She did say that the Crohns disease had been diagnosed 2 years earlier, during her daughters last semester of college. The mother estimated that Ms. Ehrlich had been hospitalized at least six times, in contrast with the daughters report of two earlier hospitalizations. Neither the gastrointestinal (GI) team nor the medical student was able to locate Ms. Ehrlichs primary gastroenterologist, whose name the patient could only spell phonetically.
On examination, Ms. Ehrlich was cooperative and conversant, and appeared comfortable. Her speech was fluent. She appeared calm and unworried about her upcoming procedures. Her thought process was linear. She denied paranoia, hallucinations, or suicidality. Attention and both recent and remote memory were intact. She acknowledged that it had been difficult living with Crohns disease, but she was optimistic that her symptoms would improve. She denied depressive symptoms. She looked sad at the beginning of the interview, but she appeared more engaged and euthymic the more she talked. She could not explain why the team was unable to locate her doctor and became irritated when the medical student pressed more specifically to elicit further details about her prior care. She was taken to have an endoscopy and a colonoscopy at the end of the interview.
Ms. Ehrlichs endoscopy and colonoscopy results were normal. That evening, the medical student from psychiatry sat in with the GI team as they reviewed the normal results with the patient. She said she was relieved there was no longer anything seriously wrong with her. The GI team told her that she could be discharged the next morning and that she should have her internist call them. She readily agreed.
After the GI team left, Ms. Ehrlich told the student that she was feeling better already. She quickly removed her own intravenous line and started to get dressed. The student went to get the primary GI team. When they returned, the patient was gone.
The medical student spent much of the next day calling hospitals and physicians that met descriptions provided by the patient and her mother. That afternoon, one of the physicians called back and indicated that he had treated Ms. Ehrlich 6 months earlier at a hospital near her mothers home. That admission was strikingly similar: after a short hospitalization, she quickly fled from the hospital after a normal colonoscopy.
13. Diagnose the vignette below. Follow the 6-step process that we’ve discussed throughout the semester. Explain your reasoning carefully so that even if you miss the exact diagnosis, you still receive some credit.
Emma Wang, a 26-year-old investment banker, referred herself to an outpatient psychiatrist because of mood swings that were ruining her relationship with her boyfriend.
She said their latest argument was triggered by his being slightly late for a date. She had yelled at him and then, out of the blue, ended the relationship. She felt despondent afterward, guilty and self-critical. When she called him to make up, he had refused, saying he was tired of her PMS explosions. She had then cut herself superficially on her left forearm, which she had found to be a reliable method to reduce anxiety since she was a young teenager.
She said these mood swings came out of the blue every month and that they featured tension, argumentativeness, anxiety, sadness, and regret. Sometimes she yelled at her boyfriend, but she also got upset with friends, work, and her family. During the week in which she was Mr. Hyde, she avoided socializing or talking on the phone; she wouldnt be her usual fun self, she said, and would alienate her friends. She was able to work when she felt miserable, but she did have relatively poor energy and concentration. She was also edgy and self-pitying and regretful that she had chosen to waste her youth working so hard for an uncaring financial institution.
When she was feeling desperate, she would be determined to seek treatment. Soon after the onset of her period, she would improve dramatically, return to her old self, and not find the time to see a psychiatrist. During the several weeks after her period, she said she felt fine, terrific, the usual.
She said the mood swings always started 710 days before the start of her menstrual period, like terrible PMS. Her periods were regular. She had premenstrual breast tenderness, bloating, increased appetite, and weight gain. Almost as soon as her period began, she felt suddenly good. She denied alcohol or illicit substance use and had no history of psychotic, manic, or obsessional symptoms. She denied any suicidal thoughts and any prior suicide attempts and psychiatric hospitalizations. She denied allergies and medical problems. She took one medication, her birth control pill. Her family history was pertinent for a mother with possible depression. Ms. Wang was born in Taiwan and came to the United States at age 14 to attend boarding school. After graduating from an elite business school, she moved in with her older sister.
On mental status examination, Ms. Wang was a fashionably dressed East Asian woman wearing tasteful jewelry and carrying a designer bag. Her hair was slightly askew. She maintained good eye contact and was pleasant and cooperative throughout the interview. Her speech was normal in rate, rhythm, and volume. She described her mood as generally good, and her affect was full, reactive, and mildly irritable. Her thought process was linear, and she showed no evidence of delusions, obsessions, or hallucinations. She denied suicidal and homicidal ideation. Her insight, judgment, and impulse control were intact, although she noted a history of perimenstrual impairment in these areas.
14. Diagnose the vignette below. Follow the 6-step process that we’ve discussed throughout the semester. Explain your reasoning carefully so that even if you miss the exact diagnosis, you still receive some credit.
Taaj Mustafa, a 22-year-old recent college graduate, was brought to the emergency room (ER) by his friends after he appeared bizarrely silent after disappearing for 3 days. Mr. Mustafas friends reported that he had recently undergone treatment for testicular cancer, but that he had been in a good mood when they had last seen him 4 nights earlier. He had not shown up for a planned get-together the following day and had then not responded to e-mails, texts, or phone calls. They had not known how to contact his parents or relatives and had no other history.
In the ER, Mr. Mustafa related to others in an odd manner, standing stiffly and not making eye contact or answering questions. After about 10 minutes, he suddenly grabbed a staff member by the arm. While he seemed to lack a purpose or intent to harm, he refused to let go, and the staff member was unable to extricate herself until a security guard intervened. At that point, he received intramuscular haloperidol and lorazepam. During the ensuing hour, his extremities became rigid, and while lying on a hospital bed, he held his arms above his head, with his elbows bent. He was admitted to the medical service. A head computed tomography (CT) scan, routine laboratory tests, and urine toxicology were noncontributory, except that his creatine kinase (CK) was elevated at 906 IU/L. He was tachycardic at 110 beats per minute. He had no fever, and his blood pressure was within the normal range.
On examination, Mr. Mustafa was found to be a thin young man lying in bed, with his head held awkwardly off the pillow. He was stiffly raising his arms up and down. His hair was falling out in tufts. He stared straight ahead with infrequent blinks, making no eye contact. He was not diaphoretic and did not appear to be in pain. Physical examination revealed an initial resistance against any movement of his arms. When either arm was moved into a position by the examiner, it remained in that position. No myoclonus was evident. Speaking with a long latency and significantly decreased production, he expressed fear that he was dying. As he slowly expressed his anxiety, his body remained stiff and rigid. He denied auditory or visual hallucinations. He was fully awake and alert and was oriented to time and place but did not participate in other cognitive tests.
Mr. Mustafa was clinically unchanged for 3 days while he received intravenous fluids. No psychoactive medication was given. Laboratory tests, an electroencephalogram (EEG), and magnetic resonance imaging (MRI) of the brain were unrevealing, and his CK trended downward after peaking at 1,100 IU/L. On the fourth hospital day, Mr. Mustafa was given a test dose of intravenous lorazepam 1 mg and then a repeat dose of 1 mg after 5 minutes. He did not become sedated. His mental status did not change, except that his speech was slightly more productive after the second dose. Intravenous lorazepam 1 mg every 46 hours was started. After 24 hours, his rigidity had resolved, his speech was fluent and pressured, and he became very active and agitated. He paced the hallways, followed the nurses around, and tried to leave the hospital. He told staff, other patients, and visitors that he was a great artist and that he had cured his cancer. His CPK normalized and tachycardia resolved. He remained afebrile.
Mr. Mustafas parents arrived from out of town on the sixth hospital day. They reported that his only previous psychiatric history had been a depression that developed when he was diagnosed with testicular cancer 1 year earlier. Mr. Mustafa had been taking sertraline 50 mg/day and was doing well until 10 days prior to admission, when he learned that he had a recurrence of testicular cancer with metastasis to the retroperitoneum. He immediately underwent chemotherapy with cisplatin, etoposide, and dexamethasone. After receiving the chemotherapy, Mr. Mustafa had told his parents over the phone that he felt excellent but had then not returned their phone calls or e-mails. This was not entirely unusual behavior for their son, who was a sketchy correspondent, but they had become increasingly worried and finally flew across the country when they had not heard from him in 10 days. The parents also mentioned that the only pertinent family history was a maternal uncle with severe bipolar disorder, which had been treated with electroconvulsive therapy.