Case Study #5 - Abnormal Psychology

Page 1“A Collision of Two Worlds” by Robert W. Grossman

Robert W. Grossman P sychology Department Kalamazoo College

Today we are going to work in small groups on a case. Th e case we are going to use is a section of the book, I Never Promised You a Rose Garden, by Joanne Greenberg (1964, Signet). It is an autobiographical novel in which the author describes her experience of being severely mentally ill. It may take more than one class period to fi nish this activity. Let’s start by reading the whole section through out loud. Would someone please begin reading this to us?

A Collision of Two Worlds: A Critical Thinking Case Study for Abnormal Psychology

After a few hours of riding through more brown and golden country and sun-dappled town streets, the mother said, “Where is the turn-off Jacob?”

In Yr a voice shrieked out of the deep Pit: Innocent! Innocent!

From freedom, Deborah Blau smashed headlong into the collision of the two worlds. As always before it was a weirdly silent shattering. In the world where she was most alive, the sun split in the sky, the earth erupted, her body was torn to pieces, her teeth and bones crazed and broken to fragments. In the other place, where the ghosts and shadows lived, a car turned into a side drive and down a road to where an old red-brick building stood. It was Victorian, a little run-down, and surrounded by trees. Very good façade for a madhouse. When the car stopped in front of it, she was still stunned with the collision, and it was hard to get out of the car and walk properly up the steps and into the building where the doctors would be. Th ere were bars on all the windows. Deborah smiled slightly. It was fi tting. Good.

—Excerpted from p. 12 of the Signet 1978 reprint edition.

Let’s start the process of case analysis by talking about what you think is going on here.

Talk to your partner and see if anything seems confusing about this paragraph.

Question 1—In your own words, write a sentence or two describing what is happening in terms of Deborah’s experience and behaviors.

Let’s all stop here and share answers.

As students in Abnormal Psychology our next task is to list all the symptoms we can fi nd in this case. Th is course has few black and white answers. It is necessary therefore to tell exactly what evidence and reasoning lead us to our conclusions about each symptom. In addition, as in all sciences, there is a fundamental uncertainty, and so we sometimes have to go with the “weight of evidence” rather than being 100% sure of our answers.

We will organize our search for symptoms using a format that has six categories:

1. Perception 4. Behavior 2. Th ought 5. Aff ect 3. Consciousness 6. Physical complaints

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Th is is the same organization that is used when interviewing patients in what is called the Mental Status Exam (MSE). You will learn more about this exam in your text and we will hand out a more extensive copy of this outline at the end of this activity. We will start with a symptom category that is especially important in schizophrenia and other psychotic disorders: perception. Take a moment to read the following defi nitions:

1. Perception Abnormal aspects of a person’s sensory awareness of objects in the environment are listed under this heading. Key terms are:

Illusion—misinterpretation of stimulus. We always tell in which sensory system the illusion occurs. Th is week we will fi rst focus on visual illusions (e.g., mistaking a tree trunk for an adversary late at night).

Hallucination—perception of an object when no corresponding real object exists. Again, always tell in which sensory system the hallucination occurs. We will focus on:

a. Auditory (e.g., patient heard a loud voice telling him to “Take off all your clothes!”) b. Tactile (e.g., patient felt insects crawling under his skin) c. Kinesthetic (e.g., patient felt like she was falling through space) d. Visual (e.g., patient saw an angel up on the ceiling) e. Pain (e.g., patient reported a strong pain in his fore arm when no physical cause could be found)

Other types of hallucinations include olfactory (smell), gustatory (taste), temperature, and negative hallucinations (where there is an obvious stimulus and the person doesn’t experience it—e.g., one client did not see or hear his mother though she was talking in a family therapy session with him).

Talk to the other people in your group and see if anything seems confusing about these defi nitions.

When I am listing symptoms, I fi rst read a whole paragraph. I then go back over it very systematically phrase-by- phrase. In this section I would start with the sentence:

“In Yr a voice shrieked out of the deep Pit: Innocent! Innocent! ”

Work in pairs and see if you can fi nd the phrase that indicates a perceptual symptom in this sentence. Write out your answers.

Question 2a—Is the symptom an illusion or a hallucination?

Question 2b—In which sensory modality does this occur?

Let’s all stop here and share answers.

Th ere are several other symptoms in this sentence. Now let’s move on to the thought category of the MSE. Take a moment to read the following defi nitions:

2. Thought In this category we list abnormal aspects of the fl ow of ideas and associations as refl ected in the speech or writing of the patient. Most of our perceptions are things we hear and see, while thoughts are often what we believe or think about these things. Th is is usually broken down into two sections:

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Content—Th is is used when the topic of a person’s thought is unusual. Key terms include: a. Delusion—a false belief system that is clearly implausible, not understandable, or held despite clear

contradictory evidence (e.g., believing that Pepsi® commercials are secret coded messages to you that extra- terrestrials are coming).

b. Neologism—made-up words that usually have meaning only to the patient (e.g., Nganon is a word one patient used to describe a poisonous substance that she believed seeped out from her and contaminated others).

Form—Th ough we will not look at these in this section of the novel, it is important to mention that abnormal aspects of the speed and structure of the fl ow of ideas are also listed under this topic. Unusual aspects of speed can be either too slow or too fast, and range from “blocked” to “slowed” to “speeded” to “fl ight of ideas.” Th e fl ow of ideas ranges in structure from “normal” to “loose associations.”

Take a moment and ask your partner if anything seems muddy about this.

Th ere are several content of thought symptoms in this sentence:

“In Yr a voice shrieked out of the deep Pit: Innocent! Innocent! ”

Th ere are two neologisms here; one is clear and the other is subtle.

Question 3—Find both neologisms and explain why you selected them.

Th e third content of thought symptom I fi nd in this sentence is a delusion. It is a little diffi cult to fi nd.

Question 4—Quote the phrase that contains the false beliefs that the author has about the voice she hears and explain your answer.

Let’s all stop here and share answers.

Now, with your partner, analyze the next fi ve sentences. See if you can fi nd and quote the phrases that fi t the symptoms listed below the box.

From freedom, Deborah Blau smashed headlong into the collision of the two worlds. As always before it was a weirdly silent shattering. In the world where she was most alive, the sun split in the sky, the earth erupted, her body was torn to pieces, her teeth and bones crazed and broken to fragments. In the other place, where the ghosts and shadows lived, a car turned into a side drive and down a road to where an old red-brick building stood. It was Victorian, a little run-down, and surrounded by trees.

Question 5—Find two visual hallucinations.

Question 6—Find two tactile or kinesthetic hallucinations.

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Question 7—Find a visual illusion.

Question 8—Do you fi nd any other perceptual or thought symptoms here?

Let’s all stop here and share answers.

Another category of the MSE is illustrated in our excerpt. It’s called the “consciousness” category and contains so many diff erent subsections I think of it as “the depository.” In this paragraph you will need to locate symptoms from the

“orientation” and “insight” subsections below (marked with asterisks). Please read these subsections closely.

3. Consciousness Range of consciousness—Th is is a place to list any unusual aspects of a person’s degree of alertness or overall responsiveness to the environment. Coma, stupor (a person does not react to the surroundings), clouded, confused, clear, hyperalert, delirium are a continuum of some of the states of awareness we list here.

*Orientation—Does the person know who and where they are, as well as what time it is (the three spheres of person, place, and time) (e.g., one patient thought she was the wife of Henry VIII, living in prison in England during the 15th century. She was disoriented in all three spheres)?

Memory—Divided into short-term and long-term, with some distinguishing between recent (hours, days, or weeks) and distant (months and years) long-term memory.

Intelligence—Abstractly defi ned as ability to use previous learning in new situations, but operationally a test of calculation, general knowledge, vocabulary, abstract thinking, and performance tasks; e.g. “mental retardation” means the person lacks so much in these areas that the capacity to function in society is impaired.

Judgment—Abstractly defi ned as the ability to evaluate alternatives based on a particular value system, but practically evaluated in terms of:

a. Social judgment—Does the person act in ways contrary to accepted behavior in our society; e.g., going nude in public, making a living through crime?

b. Test judgment—Telling what one would do in a given hypothetical situation; e.g., “What would you do if you found an unsigned paycheck lying on the ground?” “Take it to the police” = good judgment; “Cash it in at the store and buy things” = bad judgment.

*Insight—Self-understanding; the extent of a person’s understanding of the origin, nature, and mechanisms of attitudes and behavior. In many cases, it is the degree of awareness and understanding the patient has that he or she is ill when they have obvious symptoms.

Take a moment and ask your partner if he or she is confused about any of this.

Reread the following sentences.

From freedom, Deborah Blau smashed headlong into the collision of the two worlds. As always before it was a weirdly silent shattering. In the world where she was most alive, the sun split in the sky, the earth erupted, her body was torn to pieces, her teeth and bones crazed and broken to fragments. In the other place, where the ghosts and shadows lived, a car turned into a side drive and down a road to where an old red-brick building stood. It was Victorian, a little run-down, and surrounded by trees.

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Question 9—List and give evidence for symptoms from Orientation and Insight in the passage above.

9a. Identify Deborah’s disorientation.

9b. In which sphere is she disoriented? Explain your answer.

9c. We would say she lacks insight. Can you say why?

Let’s all stop here and share answers.

As we follow along in the excerpt, in the next few sentences, there is also another very subtle abnormality, but it is listed in a diff erent section of the MSE.

4. Expressive Behavior Expressive behavior is defi ned as something unusual that another person can see or hear a patient do. In this category, we include abnormal aspects of physical appearance, movements, actions, mannerisms, and nonverbal gestures. Key terms include:

Behaviors range in unusualness from appropriate to inappropriate to bizarre (e.g., going nude in public is inappropriate; banging one’s head against the wall until the blood gushes out is bizarre).

Compulsion is a term that fi ts in this category that we will defi ne and illustrate later.

Question 10—In the sentences below, can you fi nd the unusual aspect of Deborah’s behavior?

When the car stopped in front of it, she was still stunned with the collision, and it was hard to get out of the car and walk properly up the steps and into the building where the doctors would be. Th ere were bars on all the windows. Deborah smiled slightly. It was fi tting. Good.

10a. Her unusual behavior?

10b. Where on a continuum of abnormal would you say this was (appropriate to inappropriate to bizarre)?

Let’s all stop here and share answers.

Th ere is an aspect of Deborah’s emotion or aff ect that is worth noting in this passage as well. Th is is listed in the Aff ect category of one’s mental status.

5. Aff ect Th is category involves abnormal aspects of the mood, feelings, or emotional tone of a person. Aff ect ranges from appropriate to inappropriate, and from positive to negative. Key terms include:

Flat aff ect is lack of emotional response to the environment and will be illustrated later.

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Case copyright held by the National Center for Case Study Teaching in Science, University at Buff alo, State University of New York. Originally published May 27, 2008. Please see our usage guidelines, which outline our policy concerning permissible reproduction of this work.

Th e tumor woke, angered that there were other powers contending for her allegiance, and it sent a sharp bolt through its kingdoms to remind them that it was still supreme. Deborah doubled up, gasped with pain, and began to tremble. I warned you, the Censor said. Th e heavy smell of ether and chloroform came to her and she heard her heart pounding.

6. Physical Complaints Usually seen in expressions of pain, but could be practically any complaint that a person would typically bring to their medical doctor (e.g., headaches, sleeplessness, stomach pain, fuzzy vision).

Question 12—In the passage above, can you fi nd Deborah’s physical complaint symptom?

Question 13—Th ere are three diff erent kinds of hallucinations in this section. Can you fi nd the phrases and correctly label which sensory system they are in?

Let’s all stop here and share answers.

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References Greenberg, J. (1964) I Never Promised You a Rose Garden. New York: Signet a division of Penguin Books USA Inc.

Comer, R.J. (2004) Abnormal Psychology. 5th edition. New York: Worth Publishers.

Anxiety, phobia, and depression are other terms that fi t here that you may remember from Introductory Pyschology.

Question 11—Th ere are two examples of aff ect in the above passage. Find the phrases that describe Deborah’s emotional reactions in this situation. Explain in what ways they are unusual or inappropriate.

Let’s all stop here and share answers.

Another quote from the novel illustrates the fi nal section of the MSE outline—namely, physical complaints. In this excerpt, we read about Deborah’s nonexistent tumor (pp. 81–82):