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Behavioral Science
Step 1 Casebook – Changes in the elderly
May 11th
An elderly woman comes into her doctor’s office. When the consultation begins, the woman complains that while she is sexually active with her husband, she is experiencing more pain. The woman has noticed that it has been getting worse and asks the physician why this is happening.
What are some of the sexual changes that occur in the elderly?
Although both men and women maintain their previous sexual interest, there are numerous physiological changes that occur in both men and women. For men, the time to erection is longer and there is a longer refractory period after ejaculation. Women begin to experience vaginal dryness, thinning, and shortening, which may be causing the pain this elderly woman is experiencing.
Describe some common medical conditions in the elderly population?
Common medical conditions include osteoporosis, heart disease, arthritis, and hypertension. Additional changes include a decrease in visual acuity, hearing, and renal, pulmonary, and gastrointestinal function. Importantly, the immune response and muscle mass also decrease.
Does intelligence decrease as one ages?
No, intelligence does not change. However, there are well-documented effects of aging on various specific cognitive domains, such as learning, memory, and particularly processing speed.
What psychiatric conditions are more prevalent in the elderly population?
There is a higher incidence of depression in the elderly population. Also, the suicide rate increases in this population. It is therefore important for a physician to ask appropriate screening questions to rule out depression, as well as other psychiatric conditions in all elderly patients.
By Rakesh Razdan Ahuja, class of 2010, Yale University School of Medicine; in association with Le TT, Takiar V, eds: First Aid Cases for the USMLE Step 1. New York: McGraw-Hill, 2009.
Step 1 Casebook – A student under stress
May 4th
A bright medical student is studying for the USMLE Step 1 in the library basement. Although he feels that he would much rather be enjoying the company of his friends who have decided to go to the beach that day, he knows that he has to finish his studying first. In order to empty the thoughts of the beach from his mind, he chooses to focus on his studying of behavioral sciences and smirks when he looks over the ego defenses.
What two things qualify an ego defense as a reaction to psychological stress?
An ego defense must be automatic and unconscious.
What are some examples of mature ego defenses?
Some mature ego defenses include Sublimation, Altruism, Suppression, and Humor. As a mnemonic, one can remember the phrase “Mature women wear a SASH.”
What ego defense is this medical student using?
The medical student is using suppression. He is voluntarily withholding the idea of going to the beach from his conscious awareness by focusing on behavioral sciences. The difference between suppression and repression is that suppression is a voluntary process. It is therefore important to note that suppression is an exception to the rule that ego defenses must be unconscious.
What are some examples of immature ego defenses?
Examples of immature ego defenses include acting out, denial, projection, reaction formation, regression, repression, and splitting, among others.
What ego defense would the medical student be using if he could not handle the stress of studying for the examination and instead chose to go to the beach every day?
By involuntarily withholding the idea of taking the test as a reaction to his stress, the student would be exhibiting classic repression, the basic mechanism underlying all others.
By Rakesh Razdan Ahuja, class of 2010, Yale University School of Medicine; in association with Le TT, Takiar V, eds: First Aid Cases for the USMLE Step 1. New York: McGraw-Hill, 2009.
Step 1 Casebook – A 22-year-old grieving woman
Apr 27th
A 22-year-old woman who has recently lost her father in an automobile accident comes to her psychiatrist for psychotherapy. Over the past 7 months of undergoing therapy, she has had an increasing number of symptoms such as hallucinations, including “seeing her father in the hallway,” that are not attributable to the side effects of her drugs or a part of any other obvious physical diagnosis. This morning when speaking to her physician, she begins sobbing uncontrollably and reaches out to the physician for comfort.
What is the most likely cause of the patient’s symptoms?
The patient is most likely exhibiting the symptoms of grief. It is also important to consider major depression as well.
What differentiates normal from pathologic grief?
Normal grief or bereavement typically lasts for 6 months to 1 year, during which time patients may have hallucinations and experience symptoms of shock, denial, guilt, and somatic symptoms. Unlike normal bereavement, pathologic grief is defined as lasting longer than 1 year. Pathologic grief may be excessively intense, delayed, or inhibited.
What are some possible symptoms of pathologic grief?
Common symptoms include delusions, hallucinations, and depression.
With respect to her doctor, what is the patient exhibiting?
The patient is clearly demonstrating transference. Transference occurs when a patient projects feelings about important persons in her life to her physician. In this instance, the patient is seeking the type of comfort a husband, parental figure, or good friend would typically provide. Although a physician should try to comfort his patient, he is obligated to maintain a professional doctor-patient relationship at all times.
If the physician were to treat this particular patient as if she were his daughter, what psychological terms would best describe his actions?
His actions would be demonstrating counter-transference, defined as when the physician projects feelings about important persons in his life onto the patient.
By Rakesh Razdan Ahuja, class of 2010, Yale University School of Medicine; in association with Le TT, Takiar V, eds: First Aid Cases for the USMLE Step 1. New York: McGraw-Hill, 2009.
Step 1 Casebook – Medicare vs. Medicaid
Apr 20th
Near the end of daily rounds, a 70-year-old man who has been hospitalized with a chronic condition is overheard conversing with his daughter. The daughter states, “How are we going to pay for this huge medical bill you are racking up?” The attending physician realizes that although the patient may no longer have health insurance in his retirement, there are other means by which he can obtain financial support.
What is a primary way in which this patient’s medical bill will be covered?
Medicare is a federally-run program that has two original parts, A and B, which cover hospital and doctors’ bills, respectively. It originated from amendments to the Social Security Act.
What program exists for those with very low incomes?
Medicaid, a form of federal and state assistance, exists for those who are under a set income level.
By Rakesh Razdan Ahuja, class of 2010, Yale University School of Medicine; in association with Le TT, Takiar V, eds: First Aid Cases for the USMLE Step 1. New York: McGraw-Hill, 2009.
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