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“What is Wrong with the Patient?” Part II Assessment/Diagnosis Dilemma & Running Debate • Type 1 errors (person has a mental disorder but is not diagnosed) • Type 2 errors (person does not have a mental disorder, but is diagnosed with one) famous “Rosenhan” experiment (1972) The aim of this study was to test the hypothesis that psychiatrists cannot reliably tell the difference between people who are sane and those who are insane. The study consisted of two parts with 8 pseudo-patients in 12 hospitals in 5 states. Table 1 for Part 1: Responses of staff towards pseudo-patients’ requests—“labeling effect” Response Percentage making contact with patient Psychiatrists Nurses Moves on with head averted 71% 88% Makes eye contact 23 10 Pauses and chats 2 4 Stops and talks 4 0.5 Table 2 for Part 2: Judgment of all admissions as to the likelihood that they are pseudo-patients 193 Number of patients judged Number of patients confidently judged as pseudo patients by at least one staff member 41 Number of patients suspected by one psychiatrist 23 Number of patients suspected by one psychiatrist AND one other staff member 19 Dilemma & Running Debate These were the desperate questions that insurance companies raised in 1970s: Were patients in psychotherapy “medically ill”? Was psychotherapy cost effective compared to alternative treatment methods? How predictable were the costs given the frequency and length of treatment? Irony • Alan Stone, then President of the American Psychiatric Association (APA) in 1976, concluded that social psychiatry and social activism, “carrying psychiatrists on a mission to change the world, had brought the profession to the edge of extinction.” • During the DSM-III’s drafting in the latter half of the 1970s, representatives from Blue Cross/Blue Shield and Aetna virtually begged Spitzer and his task force to standardize the manual’s diagnostic criteria so that insurers could separate legitimate mental illnesses from non-psychiatric problems like “floundering marriages, trouble raising children, and the difficulties in finding meaning in life.” • As the insurance companies saw it, “Medical insurance should only be asked to cover medical mental disorders. Insurance is meant to pay for the sick, not the discontented who are seeking an improved lifestyle. We need your help in differentiating between those who have mental disorders and those who simply have a problem.” Have the NIMH and psychiatrists lost their way? Most of the well-trained, capable psychiatrists of the 1970s no more wanted a patient base composed of the seriously mentally ill than most of the clinical psychologists and psychiatrists of today. Mental health providers today, as then, favor the “worried well,” those patients (“clients”?) whose symptoms closely resemble people with ordinary personal/life problems. WHY? These people: (1) have insurance coverage and/or sufficient financial means, they (2) rarely trigger emergency calls on weekends, and they (3) have relatively easily treated mental illnesses/disorders/problems (THEY ARE VERY “affirming patients”) Examples Sexual Dysfunction in the United States Prevalence and Predictors Edward O. Laumann, PhD; Anthony Paik, MA; Raymond C. Rosen, PhD JAMA. 1999;281:537-544. Objective To assess the prevalence and risk of experiencing sexual dysfunction across various social groups and examine the determinants and health consequences of these disorders. Design Analysis of data from the National Health and Social Life Survey, a probability sample study of sexual behavior in a demographically representative, 1992 cohort of US adults. Participants A national probability sample of 1749 women and 1410 men aged 18 to 59 years at the time of the survey. Main Outcome Measures Risk of experiencing sexual dysfunction as well as negative concomitant outcomes. Results Sexual dysfunction is more prevalent for women (43%) than men (31%) and is associated with various demographic characteristics, including age and educational attainment. Women of different racial groups demonstrate different patterns of sexual dysfunction. Differences among men are not as marked but generally consistent with women. Experience of sexual dysfunction is more likely among women and men with poor physical and emotional health. Moreover, sexual dysfunction is highly associated with negative experiences in sexual relationships and overall wellbeing. [sounds fairly ENVIRONMENTAL] Conclusions The results indicate that sexual dysfunction is an important public health concern, and emotional problems likely contribute to the experience of these problems. ED: a common issue! Do you have ED? What Paxil CR Treats: If your doctor has prescribed Paxil CR for you, you are now taking an FDA-approved medication proven safe and effective for the treatment of depression and panic disorder. It Could Be Depression. If you have felt persistent feelings of worthlessness and hopelessness, or have an inability to feel pleasure or take an interest in life, you may have depression. Learn more about Depression. It Could Be Panic Disorder. If you have experienced repeated feelings of intense, sudden terror or impending doom, racing or pounding heartbeat or even chest pains, you may have panic disorder. Learn more about Panic Disorder. It Could Be Social Anxiety Disorder. If you have felt excessive, persistent fear and avoidance of social or performance situations, accompanied by sweating, shaking, tense muscles, or a pounding heart, you may have social anxiety disorder. Learn more about Social Anxiety Disorder. Record Sales of Sleeping Pills Are Causing Worries by STEPHANIE SAUL Thank you for responding to our AMBIEN CR offer. Simply follow the instructions and fill out the form below to: Get your 7-day Free Trial Offer Certificate Sign up for email newsletters Or sign up to receive both Disease Information: Depression More than 18 million Americans suffer from some type of depression, and one in eight persons need treatment for depression during his or her lifetime. Depression is not a character flaw; it is neither a "mood" nor a personal weakness that you can change at will or by "pulling yourself together." OCD Many healthy people can identify with having some of the symptoms of obsessive compulsive disorder (OCD), such as checking the stove several times before leaving the house. But OCD is diagnosed only when these activities take at least an hour a day, are very distressing, and interfere with daily life. Bulimia Bulimia nervosa is a disorder in which frequent episodes of binge eating are almost always followed by purging (ridding the body of food). Purging can involve vomiting, taking large doses of laxatives or diuretics, exercising compulsively, or fasting. Panic Disorder Panic disorder causes repeated attacks of intense fear in response to ordinary situations. This anxiety disorder can cause physical symptoms like shortness of breath, a racing heart, trembling, dizziness, chest pain, and stomach upset. A person having a panic attack may fear they are dying or "going crazy." Learn about depression, obsessive-compulsive disorder, bulimia, and panic disorder in this section. The more you know about these illnesses, the more you can do to manage and recover from them. “Pfizer Launches 'Zoloft For Everything' Ad Campaign” the ONION Premenstrual dysphoric disorder (PMDD) isn’t just part of "being a woman." It’s a real medical condition, and it causes real suffering. PMDD is much more serious than PMS. If you have PMDD, learning more about it can be the first step toward feeling better and getting control of your life again. Limits of Categorical Classifications of Mental Disorders Based on Symptom-Driven Diagnoses (1) co-occurring/comorbidity is rampant generally only about 12 truly unique, separate diagnostic entities/mental diseases (2) thus, assessment/diagnostic instruments often useful for multiple diagnoses (3) which is why several psychiatric drugs treat multiple disorders (4) structured disorders: hysteria, anorexia, MPD gender, cultural eras, clinicians shape specific manifestations of underlying disorders female: hysteria, anorexia/bulimia, more internalized disorders male: substance-abuse disorders, aggression, more violent-oriented behaviors Case Study: Alex McCarty