Behavioral Science and Introduction to Psychiatry
Year 1 Interdisciplinary Foundations of Medicine (IFM) Program
Orientation, Introduction, and Policies 2009-2010
Bryce Templeton, M.D., M.Ed. Course Director: e-mail: bryce.templeton@drexelmed.edu Office location : Friends Hospital Roosevelt Boulevard Office telephone : 215-831-6927
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Introduction:
Welcome to the College of Medicine! And welcome to the beginning of three years of instruction regarding the behavioral sciences and psychiatry. The three years of required instruction will include the following: Year 1 Behavioral Science and Introduction to Psychiatry Year 2 Psychopathology Year 3 Clerkship in Psychiatry – 6 weeks in length Also: Year 4 Electives will be available to all students. Electives include advanced inpatient psychiatry, the consultation service, child psychiatry, and a research option (primarily library-based). In addition, the psychiatry pathway program is an option for those students considering undertaking psychiatric residency training.
Faculty
George Gardiner, M.D., Psychiatrist, Community Behavioral Health Theodore Lidz, Ph.D., Research Psychologist, Substance Abuse Research Team Sam Parrish, M.D., Pediatrician, Associate Dean for Student Affairs and Admissions Susan Hyman, Ph.D. Clinical Psychologist Richard Malone, M.D., Child Psychiatrist Susan McLeer, M.D., Chair, Department of Psychiatry Ralph Petrucci, Ed.D. Clinical Psychologist, Heart Failure and Transplant Service Dilip Ramchandani, M.D., Psychiatrist; Director, Medical Student Education in Psychiatry Barbara Schindler, M.D., Psychiatrist, Vice Dean, Educational and Academic Affairs Nadine, Schwartz, M.D. Child Psychiatrist, St Christopher‟s Hospital Bryce Templeton, M.D., M.Ed. Psychiatrist, Course Director Sunil Verma, M.D., Psychiatrist, Chief, Consultation Service, Hahneman University Hospital Pogos H. Voskanian, M.D., Forensic Psychiatrist Mark Woodland, M.D. Obstetrician and Gynecologist
Goals of the Course:
To enhance your understanding of behavioral science as applied to the care of all patients; To introduce you to some of the major psychiatric disorders and certain aspects of the treatment and care of psychiatry patients.
Organization of the Course:
Your courses in gross and microscopic anatomy, biochemistry, genetics, microbiology, nutrition, etc have been organized to include a significant amount of interconnection among one another. A few other topics are commonly deemed appropriate to include in the first year of medical school but are difficult to integrate with the above basic sciences: Physician and Patient (emphasizes medical interviewing skills), Principles of Medical Research, and Behavioral Science. The College of Medicine faculty have concluded that you derive value from beginning to develop medical interviewing skills during your first year of medical school.
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When the IFM curriculum was first established, the course director was asked to distribute the existing behavioral science class session throughout the first year. In a few instances, topics which are typically covered in behavioral science textbooks could be linked to topics covered in some of the modules: e.g., alcoholism and violence in the Gunshot Wound Module. But many important topics could not be easily linked to the existing modules. For a few of you, this will be very distressing. The information which we present in the Behavior Science course will include significant connections to the Physician and Patient Course, but not always at the same time. Your interaction with standardized patients and hospital patients will be enhanced if you try to apply some of the knowledge and concepts introduced in behavioral science to the latter patients. What psychosocial data should you obtain from your Year 1 standardized patient or hospitalized patient regarding the patient‟s development from childhood on through early adult life. Was the patient‟s development normative,-- loved, nurtured, and healthy? Was it aberrant, --- abused, neglected, or adversely affected by serious illness and therefore abnormal? How will the data about the patient‟s development affect the patient‟s ability to cope with the current medical or surgical problems with which the patient is now confronted?
PLACE THE 2009-2010 SCHEDULE HERE
Outlined on the next two times, and assigned readings:
pages is a list of the class sessions for Year 1 including the date,
Attendance at Class Sessions: I am sympathetic to the reports of a number of very able students who feel they can learn faster and more efficiently in the privacy of their apartment or in the library. In addition, I hope that many of you will find attendance at the class sessions helpful. Classroom Interviews of Patient: During several class sessions this year, we will be showing interviews with patients: a few videotapes of so-called standardized patients (“SPs”, i.e., actors); one videotape of an actual patient; and we hope to include a live interview with a patient who will be present in the classroom. Because of the problems in assuring patient confidentiality, we generally do not allow any videos of actual patients to be added to the College‟s streaming video system, neither live-patient interviews, nor videotaped interviews; a single instance of such a video being copied and placed on the internet would be a malpractice disaster for the instructor and for the College of Medicine. I will let you know in advance about which class sessions will include interviews which will not be recorded for the website. Most instructors who use videos are unwilling to come back and show them a 2nd time for students who did not attend the scheduled class. Classroom Recitations: From time-to-time (about 8 – 12 times during the year), I will request that the class recite, in unison, a definitional phrase for an important term. I typically ask the class to do so three times in quick 3
succession. Videotapes of interviews with standardized patients (SPs) will, in all likelihood, be available on the web. but !” A year ago, as I entered the parking garage one afternoon, an internist colleague told me that earlier that day she asked a group of third-year students for the definition of “dementia”. She was incredible amused but also very pleased, because the group responded quickly and, in unison, with a brief accurate definition (“multiple cognitive deficits”). Your fourth-year class predecessors have told me, “You know, those stupid class recitations that you made us yell, really helped us learn stuff! Keep doing it!” If you elect to skip most class sessions, I urge you to undertake the verbal recitation of the abbreviated definitions just as your classroom colleagues will be doing. I plan to include A FEW, especially important unison recitations throughout the year. also very pleased, because the group responded quickly and, in unison, with a brief accurate definition ASSIGNED READINGS 2009-2010 Almost all of the assigned readings will refer to the following text: Fadem: Behavioral Science in Medicine, 2004. The assignments for individual class sessions are shown above. In addition, your Syllabus will have a few additional readings about which we will call attention as the year progresses. Tips on Studying and Evidence-based Education Some students voice distress that they have read the Syllabus and read the text assignments and yet their exam grades seem to suggest they are in jeopardy of required remediation. Watching lectures and reading the text are typically insufficient for most medical students. Reading is a relatively passive, far less effective learning technique; unless you have a photographic memory somewhat comparable to Teddy Roosevelt or Winston Churchill, you need to undertake ACTIVE study approaches. Research on high education study techniques over the past 15 years have shown that reading assigned material, once, or even twice, is insufficient to learn the required information. Based on these studies, McDonald recommends closing the book and reviewing what you have learned: summarize what you have learned aloud or, if you are too shy, summarize by writing down what you have learned. Studies show that this approach maximizes retention of the information and makes it more likely that one can use the information in various problem solving settings. McDonald, Mark A: Contemporary Educational Psychology, 2009 McDonald, Mark A. Psychological Sciences, April, 2009 Other active study techniques are also available. Undertake some studying with a colleague or a group in which questions are asked of each other and recitation takes place; groups which place a heavy emphasis on one-upsmanship should probably be avoided. Make and study your own special outlines of the material. Finally, the creation of and study of flash cards regarding some of the content, especially definitions, criteria for disorders, etc. can be a very active, and thereby a successful study approach. I hope the above suggestions will be helpful not only in improving your exam scores, but also in providing you with information which you will use later in medical school and residency training.
Evaluation of Students
Grades will be based on the results of five multiple-choice examinations which will be administered at the end of each of five modules in which we have class sessions (see above). The level of detail required in this course will parallel the level of detail required in your other Year 1 courses. 4
Details of anatomy Better understanding of body structure; Details of biochemistry Better understanding of body chemistry; Details of physiology Better understanding of bodily functions; Details of genetics Better understanding of the role of inheritance; Details of behavioral science Better understanding adaptation to illness. Source of Examination Questions Virtually all of the exam questions are derived from one or a combination of the following: classroom presentations including PowerPoint slides; syllabus material; and/or readings in your assigned text. When each test item is prepared in draft form, a line below the test question on my copy designates from what slide, from what Syllabus page, and/or from what text page the test question is derived. Those students who express concern about the lack of the connection between test questions and the course content are demonstrating insufficient familiarity with the assigned and presented material. students acknowledge that many of their non-attending colleagues review the streaming video material by speeding up the video presentation. Such a study approach makes it very difficult to acquire a basic understanding of the course content and may account for the expressed concern by some students about not recognizing the material required to answer test questions. In preparing multiple-choice questions for this course, each data bank question is tagged with its link to material presented in a class session, in the Syllabus, and/or in one of the assigned readings. Comments from occasional students who express dismay about test questions suggesting that they have not been covered in the course are simply reflecting a failure to study and review the assigned material. Grading of Examinations: Although historically, many instructors assign 70% correct as the passing grade for exams involving widely varying subject matter, research on examinations (i.e., evidence-based education findings) shows that the distribution of scores on an examination is determined by the following factors: Mean percent correct for all examinees = (average difficulty of the test questions)(student knowledge)(K) Organizations like the National Board of Medical Examiners (NBME) and the various specialty boards (e.g., the American Board of Surgery) tend to produce examinations year after year with very similar distribution of scores and also exams which are moderately difficult. For example, for many years the distribution of exam scores for the Step 1 exam taken at the end of your 2nd year and the distribution of scores for the Step 2 exam taken near the end of your 4th year, ranged in the 60s% correct [Hubbard: Measuring Medical Education, 2nd ed, p 51, 1978] Thus, if the NBME had utilized the popular 70% as the passing grade, half of U.S. medical students taking those exams would have failed. Although the NBME failure rates varied, they rarely exceeded 12% for first-time takers. Over the past several years, the mean percent correct of behavioral science grades has shown greater variability ranging from about 68% up to ~80%. The variation has been closely related to how much pre-exam directions we have provided to students about where the focus of study should be directed for a given upcoming exam, -- the more hints, the higher the mean percent correct. However, the perceived difficulty of a behavioral science exam by the class as a whole has limited bearing on an individual student’s risk for required remediation.
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Feedback on Examination Performance: At the end of each examination, we will provide a listing of the examination questions. This listing will include the following information: a key phrase to indicate the subject of the test question; a designation of the faculty member who wrote and/or authorized the use of the question in the exam; and a reference to where the answer to the question can be located within the assigned readings. Course Pass-fail Determination: Your final course grade will be based on the accumulation of points from all five modular exams, each test question counting the same as every other question. We do not designate a passing score for each exam; however, after each exam, we try to notify those students whose exam and/or cumulative scores are at the low end of the distribution to let those students know that that they are not learning enough of the course content. Distribution of Cumulative Five-Exam Raw Scores for Behavioral Science
Histogram
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Determining the Need for Remediation: At the end of the academic year for each student, we sum the five exam grades for each student. With that data, we prepare a histogram showing the distribution of the year-end cumulative scores for the entire class (see the above illustrative histogram of the grade distribution for a recent year) . If all of the students in a given class were closely bunched together at the low end of the curve, all students would receive a passing grade with no requirement for remediation. That has never happened. Typically, the distribution of scores shows an extended tail to the left (i.e., as shown in the above histogram, the lower end of score distribution from 105 points to approximately 118). As a result, in any given year approximately 5 – 12 students are required to undergo a remediation exam usually given within 2 – 3 weeks after the end of the course. We require this remediation for two reasons: we feel that those students who are required to remediate need a more comprehensive knowledge base in an area which they will utilize in working with patients; and requiring these low-performing students to remediate will make them slightly less vulnerable for failing the Step 1 exam. Remediation Process: Most students who have been required to remediate have reported that they had failed to take the course seriously and had not studied the Syllabus nor the readings; and/or they were having trouble with one or more other larger courses and had concluded that they needed to use all of their study time for one or more of the larger courses. Most students who have been required to remediate, have taken the remediation process seriously, have studied the Syllabus and assigned readings thoroughly, and have passed the remediation exam on the first attempt. A few remediating students did not pass the remediation exam on the first attempt. If a student fails to pass the remediation exam, we are required to report the student to the Year 1 & 2 Promotions Committee which might be reflected on the student‟s transcript. The latter group usually advises another period of remediation followed by retesting. However, students are required to complete all of the first year requirements before being 6
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allowed to begin Year 2. Thus, students who are at risk for remediation and who purchase airline tickets for a few days after the last regularly scheduled exam in late May, place themselves at increased risk for not being able to begin Year 2 with all of their fellow students. Remediation Exams: The remediation exams typically consist of the following: approximately 30 short answer questions focusing heavily on definition of terms; a few clinical vignettes to assess diagnostic skills; a listing of major data-gathering patient evaluation blocks of information; and a few other short-answer questions. The questions are drawn from the material covered throughout the entire year. Your Evaluation of the Course: We value student feedback. You will note that during most of the class sessions, we distribute about 20 rating forms to students and attempt to vary the location in the lecture hall to avoid making an undue hardship for a few students. Student feedback has brought about a number of helpful changes. One common critique concerns what some view as the lack of organization of the course. If you recommend reorganization: the organization of the course has been outlined above. Almost every year we have made some changes which we have felt improved the organization. For example, over the last several years, we have tried to develop a closer tie between the Behavioral Science course and the Physician and Patient Course. However, simply stating that you dislike the current organization is not helpful and will not bring about any changes. If you develop some ideas about how the organization might be improved, I recommend that you review your suggestion with 3 – 5 colleagues, see if your colleagues agree with your the proposed changes, and then present your plan to me as a group recommendation. I will review your recommendation(s) with my colleagues and determine if we can make the recommended changes.
Introductory Course Material
Now, we will turn away from details about the course logistics to the content of the course including various aspects of behavioral science and psychiatry. We will start with the problem of the stigma of mental illness and how that might affect your approach to behavioral science and psychiatry and your care of your patients. Stigma and Mental Illness Stigma – definition: (as applied to medical care)– negative attitudes regarding certain illnesses and/or the physicians and other health care provides which impair the provision of effective medical care and/or the ability of patients to obtain good care. All illnesses involving any significant loss of function are associated with some stigma. Most individuals are very secretive about any potentially disabling disorder: many employed adults prefer to keep diagnoses from their bosses, coworkers, and sometimes even close friends -e.g., cancer, tuberculosis and other communicable diseases, and especially sexually transmitted diseases (STDs, especially AIDS). Example: About a year ago, shortly after having a seizure, Supreme Court John Roberts was quoted in the press, adamantly stating that he would not disclose any additional information about his two episodes of already press-reported seizures. Teenagers: often secretive about such chronic illnesses as diabetes or cystic fibrosis, feeling that they are „damaged goods‟, and fearful of rejection by peers. 7
Mental illness: also associated with feelings of shame & desire for privacy. Added stigma for special groups of employees, eg, military personnel, police officers, and transportation personnel such as train engineers, bus drivers, etc), fearful, often with good reason, of possibly being suspended, being taken off active duty, and/or being fired. Stigma and the News Media: the media typically refer to a psychiatrist as “a shrink” whereas most other medical specialists are not referred to by slang labels, let alone slang labels which have such a pejorative connotation. Stigma and Commercial Films: famous unflattering psychiatric examples include --Snake Pit, a portrayal of a ineptly managed mental hospital; and One Flew Over the Cuckoo’s Nest in which Jack Nicholson gets rough treatment at the hands of mental hospital staff members who are portrayed as non-empathic and vindictive. Exception: Ordinary People in which a psychiatrist in a fairly effective manner, assists a teenager struggling over the accidental boating death of his parent-preferred brother. Stigma about Psychiatric Care Among Patients: A few psychiatric patients advertise being “in therapy”; most do not. Celebrities, especially politicians, feel strongly that any psychiatric attention must be kept hidden from the public. Example of the risk: Thomas Eagleton; in 1960s was nominated as a vice presidential candidate. press discovered he had history of electroconvulsive therapy for depression; had done well ever since; was immediately dropped from the national VP ticket. Many patients omit telling primary care physician about their psychiatric treatment. Stigma among Non-psychiatric Physicians: Many MDs prefer to send a patient to a psychologist; these MDs feel apprehensive that the patient will be less likely to get angry about a referral to a psychologist than to a psychiatrist; (many psychologists are excellent psychotherapists but, in most states, are not legally allowed to prescribe medications. Stigma and the Medical Faculty: Common non-psychiatric faculty response to student expressing interested in psychiatric career: “Why would you want to do that?” Common academic medicine philosophy: “You need to rule out everything else first before considering that the problem is all in the patient‟s head.” Danger: if a patient is depressed and possibly suicidal or having trouble controlling anger, your delay in discovering such distress may be disastrous for your patient, for the patient‟s family, and possibly for you (e.g.., a malpractice action against you in the case of death of the patient or the killing of an infant by a parent). Stigma and Medical Student Attitudes: Medical student assessment of field: (overheard in the Queen Lane hallway) “I don‟t believe in any of that Freudian stuff.”; how unscientific! Most medical school teachers hope that you will accept or reject hypotheses based on a review study findings. We hope you will apply the same approach to concepts in the behavioral sciences and in psychiatry.
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Stigma with the U.S. Medical Insurance System: many medical insurance companies provide very limited coverage for psychiatric care, e.g., a maximum of 30 inpatient days for a lifetime and five follow-up outpatient visits within a given year (often no provision for ambulatory psychiatric care). For those medical insurance carriers which do include some coverage for mental illness, the corporations usually farm out the coverage of psychiatric care to a second insurance corporation. Thus, most mental health coverage in the Philadelphia area including that for Blue Cross and Aetna is handled by the Magellan Corporation. Such third-part payers typically require an advanced request by the practitioner for psychiatric care which the insurance carrier may or may not approve. Advertisements by managed care corporations and hospitals tend to avoid the word “psychiatry”. For example, a recent advertisement by Universal Health Services, Inc., in saluting the chief of their psychiatric services covering 7 Philadelphia area hospitals, labeled that division of their corporation as UHS‟s “Behavioral Health Division” and noted her responsibilities included “behavioral health facilities “ [Phil Inquirer, 7/11/07, A9] Similarly, pediatricians have developed a subspecialty of “behavioral pediatrics”.
Nature of Evidence
Not all medical techniques, approaches, treatments, etc. have been studies with controlled clinical trials. Example -- use of Patient Names: All doctors use patient names. Some try to systematically use last names; some use first names; and some prefer to ask the patient for his/her preference. Experts have recommended certain approaches. So far, we have no controlled clinical trial findings on the best approach for use of patient‟s name. Conclusion: there will be many other challenges regarding patient care for which no evidence–base guidance will be available. Value of Anecdotal Data: We will provide you with considerable evidence-based behavioral science and psychiatric findings; We will also draw on anecdotal material. Precedent for doing so: Autopsies: the examination of the deceased and a resulting report of the apparent cause(s) of death has provided important findings regarding individual patients. Morbidity-mortality conferences: monthly hospital meetings to review clinical findings of patients who have died in the hospital sometimes including but not always including autopsy data. Published case reports: peer-reviewed journals still publish some case reports than they once did, a number of journals still do so. (see examples in references at the end of this material). For example, the several papers concerning memory studies of the patient Henry Gustav Molaison (identified in peerreviewed reports as “H.M.”) who had had his medial temporal lobes removed bilaterally in an effort to control his seizure disorder [Science 322:1765, Dec 19, 2008] Accident analyses: federal and state agencies and insurance carriers routinely undertake investigations concerning incidents involving either crashes and/or serious injuries or deaths associated with airline transportation, maritime disasters, train crashes, mining disasters, space-flight tragedies, etc. For example: the Cypress plane crash and the discovery of an apparent pilot-copilot communication problem which prevented them from detecting the failure of cockpit pressurization. [NYT ~9/7/05]; the study report published in December 2008 concerning the space-shuttle Columbia tragedy with recommendations as to how to make future flights safer [Phil Inq, 12-31-008, A-1].
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Value of Clinical Vignettes: Many students report that brief clinical vignettes (1) some find vignettes provides a useful mnemonic advantage in helping to recall a disorder, a clinical syndrome, or a complication of treatment; and (2) others find that vignettes help them understand a more abstract concept. Psychiatric Disorders and Productivity in Life Many individuals who have had mental illness have been able to recover and have a good adjustment and/or good recovery and have been very productive. The National Alliance for the Mentally Ill (NAMI) is a lay group which lobbies for better psychiatric care for their impaired relatives and for more psychiatric research. This group has produced a list of famous and/or productive individuals who have experienced mental illness at some point in their lives; some succumbed from a psychiatric illness. The following is a modification of a NAMI list: Alcoholism: Fitzgerald, F. Scott, author; Poe, Edgar Allen, author; and many others. Anorexia: Carpenter, Karen: half of a brother-sister pop song duo; though very productive for about a decade, she eventually died suddenly of her anorexia. Bulimia: Princess Diana, but her death was most likely due to the chauffeur‟s alcohol-impaired driving. Depressive disorder, probably major depression: Ludwig Beethoven; Winston Churchill; Michael Faraday, scientist; James Forrestal, Truman‟s Secretary of War, developed delusions and jumped to his death from the 17th floor of the Bethesda Naval Hospital; Abraham Lincoln: Sherwin B. Nuland, M.D. Professor of Surgery, Yale Univ. College of Medicine, a multi-book, readable author who credited electroshock therapy with having “saved my life”; William Osler, M.D. well-known Hopkins internist whose grief following his son‟s WW I death progressed to disabling depression; Ann Sexton and Sylvia Plath, both well-known and productive poets who committed suicide in their mid 30s; and Mike Wallace, television commentator and reporter. Bipolar (manic-depressive disorder) disorder: Patty Duke, actress; Kay Jameson, Ph.D., Professor of Psychiatry at Johns Hopkins and a nationally recognized expert on bipolar disorder and author of An Unquiet Mind: A Memoir of Moods and Madness, a book about her struggle with mental illness. Robert Schumann, composer; and William Styron, writer and author of Darkness Visible; a Memoir of Madness. Postpartum depression: Brook Shields (her illness was reported in her autobiographical account, Down Came the Rain. Her decision to obtain treatment was publically challenged by Tom Cruise, as part of his support of the Scientology group. Schizophrenia: John Nash, Nobel prize-winning Princeton economist and subject of a book and the movie, A Beautiful Mind; Chester Minor, M.D., Civil War surgeon, convicted murderer, extensive contributor to the Oxford English Dictionary, and object of S. Winchester‟s Professor and the Madman. Specific phobia (fear of flying): John Madden, retired television sport commentator. Stuttering: Mrs. John (Annie) Glen, wife of astronaut John Glenn [Am Med News, 4/10/06] Although I could add many other names to the lists of individuals with depressive disorder, alcoholism and even bipolar disorder, there are very few individuals with schizophrenia who have had successful careers. We will discuss more about the reasons for this later in your studies of schizophrenia.
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Normality:
How do we decide what is normal and what is abnormal? Consider the following examples of behavior. Is expressing aggression normal? losing one's temper verbally, at age 4? losing one's temper verbally, at age 44? losing one's temper and threatening to injure another? losing one's temper and threatening to kill another? How much risk-taking is normal? rock climbing? driving 70 mph on an interstate highway? driving 90 mph on an interstate highway? being a test pilot? climbing Mt. Everest and surviving? being an astronaut? exploring the ocean floor at 1.5 miles below the surface? handling poisonous snakes? playing Russian roulette once? climbing Mt. Everest and dying? Is having a vision of a person in the absence an external stimulus normal? having a vision of a spouse or child in the absence of an external stimulus shortly after the death of that person? Is experimenting with alcohol and/or street drugs normal? binge drinking once/wk with peak blood alcohol at 0.14%? binge drinking once/wk with peak blood alcohol at 0.19%? binge drinking and driving with a blood alcohol at 0.16%? binge drinking 1/mo with peak blood alcohol at 0.14%? binge drinking once with peak blood alcohol at 0.24%? Are mood changes normal? mood swings of one-week duration with no suicidal thoughts? mood swings with occasional thoughts about dying? mood swings with a periodic wish to die? postpartum blues? swallowing 6 pills after breaking up with a lover? swallowing 18 pills after breaking up with a lover? feeling morose after losing a loved one? being depressed when over 70 years of age? Is workaholism normal? working a 60-hour week? an 80-hour week? working a 100-hour week? Are eccentric individuals psychologically normal? Are homeless individuals normal?
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Is unethical/illegal behavior normal? cheating once on a college exam? cheating regularly on college exams? hiding a $300 honorarium from one's income tax? hiding a $3,000 income from one's income tax? Is a more laid-back lifestyle normal? working a 30-hour week? remaining on welfare? seeking long-term social security disability benefits for intermittent back discomfort? seeking long-term social security disability benefits following development of multiple sclerosis? Above examples illustrate the complexity of decisions regarding forms of behavior some of which are deemed normal some of the time. Is normal that which is common or typical? Is normal strictly in the eye of the observer? Our concepts of normality have important fiscal implications (Will a health maintenance organization – HMO - pay for Viagra?), legal implications (Should the mother who killed her infant be deemed not guilty by reason of insanity?), and clinical implications (Is he depressed enough to encourage treatment and/or referral?). Normality Researchers have given considerable thought to how best to define "normal" and "normality". The concept of normality can be viewed from at least three perspectives [Offer & Sabshin, KF&S, 1980]: normality as ideal or utopian; normality as the average or mean. normality as healthy; High prevalence of atherosclerosis beyond the 4th decade of life, though normative (i.e. very common) is neither regarded as inevitable nor healthy and therefore is viewed as not normal. Prevalence of depression beyond the 4th decade of life is not regarded as inevitable nor healthy and is therefore viewed as not normal. Approach in this course re normality: that which is regarded as healthy, --i.e. human conditions (a) which are relatively free of major dysphoria (a generic term meaning a feeling of unpleasantness, anxiety, uncomfortable anger, and/or depression), and (b) which include the ability to work productively, the ability to get along with others, and the ability to have satisfying, loving relationships with a few. “I don‟t believe in labeling people!” philosophy: a vast majority of your clinical studies in medical school will focus on labeling people with a wide variety of disorders, -- essential hypertension, type I diabetes mellitus, major depression, third-stage metastatic carcinoma of the lung, etc. Such labeling is an essential component of conducting research on and treating various diseases and disorders. Defining (Labeling) Mental Disorders and DSM-IV Hospital coding manual contained an agreed-upon listing of diagnostic terms in order to designate, especially at the time of discharge from the hospital, what diagnoses should be applied to each patient with an assigned code number for each diagnosis. Resulting data helps organize epidemiologic studies, plan controlled clinical treatment trials, and on planning the allocation of hospital and related resources. Diagnostic and Statistical Manual IV TR. Since 1952, the American Psychiatric Association has published a supplementary coding document which contains their approved listing of psychiatric diagnoses. This document, the Diagnostic and Statistical Manual (DSM) contains a list of recognized psychiatric diagnoses [DSM-IV, p xvii) which 12
psychiatrists and other physicians utilize in assigning diagnoses to hospitalized patients with psychiatric disorders. Prior to 1980, epidemiologists across the globe were puzzled about significant difference in the incidence and prevalence of certain psychiatric disorders. Researchers in the United Kingdom and the United States were especially puzzled about differences in prevalence of two of the major psychiatric disorders, schizophrenia and bipolar disorder. In exploring the reasons for these differences, researchers discovered that the investigators in the U.S. and the U.K. were utilizing different diagnostic criteria for these disorders. Through collaborative efforts, an international group of investigators reviewed a variety of research data and jointly develop research-based criteria initially for these two disorders and eventually for many other psychiatric disorders. As a result, with the publication of a new DSM edition in 1980, the DSM-III, the researchers and practitioners jointly produced a document which placed a heavy emphasis on lists of observed clinical findings and criteria for the number of findings to be identified in order to make a diagnosis. A major goal was to improve the reproducibility of psychiatric diagnoses which in turn would assist in conducting controlled clinical trials of various forms of treatment; and would improve our ability to treat patients with techniques based on the best available research findings. World Health Organization, (Switzerland): has developed a parallel listing of diagnosis, the International Classification of Diseases (the current edition is ICD-10). The latter closely parallels but is not quite identical to DSM-IV. Defining a psychiatric disorder: DSM-IV (1994) defines a mental disorder as a “. . a clinically significant behavioral or psychological syndrome or pattern that occurs in an individual and that is associated with present distress (e.g., a painful symptom) or disability (i.e., impairment in one or more important areas of functioning) or with a significantly increased risk of suffering death, pain, disability, or an important loss of freedom.” [DMS-IV p xxi]. Organization of DSM: The manual includes “16 major diagnostic classes”: e.g., delirium, alcohol-induced disorders, schizophrenia and other psychotic disorders, anxiety disorders, etc. Purpose of the above classification: to place disorders with somewhat similar clinical findings in close proximity in order to facilitate the process of differential diagnosis. [DSM-IV, p 9] See following example of criteria for PTSD: DSM-IV Diagnostic Criteria for Posttraumatic Stress Disorder (PTSD) Exposure to a traumatic event involving threat of death or serious injury Patient‟s response involving intense fear, helplessness, or horror; Recurrent and intrusive recollections of the event. Distressing dreams of the event Acting or feeling like the event was recurring (hallucinations, flashbacks, etc) Avoidance of related stimuli (e.g., places or settings which re-invoke fear). Persistent symptoms of increased arousal not present before the event Duration: symptoms for more than 1 month. Psychiatrists would be delighted if we had pathognomonic findings for these psychiatric disorders (findings which give high certainty regarding a diagnostic process) e.g., serum glucose findings for diabetes; biopsy data for cancer of the lung. But we do not. DSM enthusiasts: some clinicians feel that these definitions have assisted researchers in epidemiologic research and in controlled clinical trials of various forms of intervention and have enhanced communication among physicians. DSM skeptics: other thoughtful clinicians feel that such definitions fail, at times, to deal with the complexity of human existence, mental disturbance, and human adaptation or coping. 13
TERMS AND CONCEPTS TO LEARN: (see Kaplan & Sadock's Glossary) The following are some terms which will come up repeatedly in your medical school studies of behavior and psychiatric disorders over the next four years. Why present them now? You‟ll have a lot of terms to learn and you need to begin to learn them now. Learn them! mood: our inner feelings ranging from feeling good, feeling down, etc. affect: the communicative aspect of mood; what we communicate about our mood through verbal and/or nonverbal means. delusions: fixed false beliefs [an example of one our recitation phrases] which are inconsistent with the person's culture and/or religion. hallucinations (pathologic): false sensory perceptions in the absence of relevant external stimuli; may be auditory, gustatory, painful, tactile, or visual. Usually regarded as pathological except during the first few months of grief involving a person to whom the aggrieved was very close (e.g. a spouse of many years) illusion: perceptual misinterpretation of a relevant external stimulus; common in children, in adults just before and after sleep, and in delirious patients; thus may or may not be abnormal. psychosis: a loosely defined, generic term which suggests that the person has lost contact with reality as evidence by hallucinations, delusions, numerous illusions, etc. Schizophrenia, bipolar disorder, and delirium a group of disorders are associated with psychotic changes, but individuals with these disorders may improve, still have the underlying disorder, but not be deemed "psychotic". mania: a mood disorder which includes elation, decreased need for sleep, sexual promiscuity, spending sprees; and, in other patients, disabling irritability, typically to the extent that the person has lost contact with reality.
Conclusion:
The Department of Psychiatry looks forward to working with you over the next three – four years and hopes that you find the rapidly advance fund of knowledge in behavioral science and psychiatry as exciting and challenging as we do.
References:
American Psychiatric Association: Desk Reference to the Diagnostic Criteria from DSM-IV_TR, American Psychiatric Association, 2000 Applbaum AI et al: A family„s request for complementary medicine after patient brain death. JAMA 299(18) 2188-2193, 2008 Davis, BT and MS Pasternack: Case 19-2007: A 19-year-old college student with fever and joint pain NEJM 356:2631-2637, June 21, 2007 Viguera AC et al Case 24-2008: A 35-year-old woman with postpartum confusion, agitation, and delusions NEJM 359(5) 509- 515, 2008. Tulsky, JA: Beyond advance directives; importance of communication skills at the end of life JAMA 294:359-365, 2005 [ a case report and discussion]
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