Diagnosing Mr. Smith
For this exercise, I divide students up into small groups and ask them
to make a differential diagnosis of "Mr. Smith." Because Mr. Smith's
case is somewhat ambiguous, making the diagnosis is not straightforward.
The exercise helps students appreciate various aspects of diagnosis,
including how to assess symptoms, how to apply inclusion/exclusion
criteria, the necessity of obtaining accurate information about the
patient, and the sometimes unavoidable ambiguity of diagnostic
categories.
Below is the handout for the exercise.
Diagnosing Mr. Smith
Mr. Smith, a sixty year old employee of a local taxation office, claims
that the IRS has been "observing Him" for the past three weeks. He
believes that some errors he accidentally made at his job have led the
federal IRS to suspect him of gross tax fraud on his own income tax
return. Even though his wife and boss have tried to convince him that
his perceptions are inaccurate, he is convinced that IRS agents are
watching his house, tapping his phone, and perhaps hiding in the attic.
Because he fears the consequences of this "investigation," he often
avoids going to work, and, when at home, draws all the curtains and
removes the phone from its hook.
Mrs.Smith reports that her husband seems to have changed significantly
since he lost his first job, which was approximately one year ago. Once
being very active fixing up the house, Mr. Smith now spends most of his
free time munching on food or dozing on the couch. Although he often
stated that he enjoys his new job at the taxation office, he sometimes
complains of "having trouble figuring out the numbers" - which surprises
Mrs. Smith since he was always very good at mental calculations. Mr.
Smith state that "all this stuff really doesn't bother me all that
much," and strongly denied any suicidal thoughts when the psychologist
asked him about this possibility. "I only came to see a shrink because
my wife and two sons suggested it."
The objective: Using the criteria below, diagnose Mr. Smith
as either a paranoid disorder or a major depressive episode.
Diagnostic Criteria for a Paranoid Disorder:
A. A persistent persecutory delusion is present (e.g., beliefs about
being conspired against, cheated, spied upon, followed, poisoned or
drugged, etc.)
B. Emotion and behavior appropriate to the content of the delusional system
C. Duration of illness of at least one week
D. Symptoms of schizophrenia are not present (e.g., hallucinations, incoherence, bizarre delusions)
E. Cannot be diagnosed as a depressive or manic syndrome
F. Condition is not due to an organic or physiological cause
Note: These individuals rarely seek treatment and often are brought for
care by relatives, associates, or government agencies. Eccentric
behavior is common.
Diagnostic Criteria for a Major Depressive Episode:
A. At least 4 of the following symptoms are present every day for a period of at least 2 weeks:
1. poor appetite with weight loss, or increased appetite with weight gain
2. insomnia or hypersomnia
3. psychomotor agitation or retardation
4. loss of interest or pleasure in usual activities, or a decrease in sexual drive
5. loss of energy or fatigue
6. feelings of worthlessness, guilt, self-reproach
7. complaints or evidence of a decreased ability to concentrate (slow thinking, indecisiveness)
8. recurrent thoughts of death, wishes to be dead, suicide attempt
B. None of the symptoms of schizophrenia are present (see above)
C. Not due to an organic or physiological cause
Note: If patient reports feeling "blue, sad, hopeless, low, down in the
dumps," etc., use diagnosis Depressive episode with Melancholia.
Note: If gross impairment of reality testing is present (e.g.,
hallucinations, delusions) use diagnosis "Depressive episode with
Psychotic Features"
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