Thoughts on the Elise question

One winter’s night, university student, Elise was found wandering the campus in her nightie. Freezing cold, she was apparently whispering some sort of mantra, possibly a prayer, she seemed terrified and distraught. Elise was taken by some other students and to the University Welfare Office. They recognised some of her symptoms and when Elise eventually spoke to a psychiatrist, she revealed that the she felt that her thoughts were being controlled by a terrorist organisation who were telling her to harm her university friends.

 Assess the usefulness of at least 2 of the 4Ds, in relation to the assessment of Elise and her needs (12)

  • Assess requires AO1 and AO3 and the extract means that we also need cover AO2.
  • As its out of 12, this will be an equal 4+4+4 split.
  • As there are 2 Ds that need to be covered this suggests 2 minutes need to be spent describing, applying and evaluating each of the Ds.
  • As its assess, its important to ensure that the significance of competing arguments is made clear and referenced in the judgement/conclusion drawn.
  • Think ATCHOO(BC)!

Davis (2009) says it can be very difficult to decide when a patient such as Elise’s problems or symptoms are severe enough to require a diagnosis. He suggests that the 4Ds (deviance, dysfunction, distress, and danger ) can be very valuable when assessing reported traits, symptoms, or conditions in order to illuminate the point of at which these factors might represent a disorder of some sort.

First let us consider deviance, which can be statistical or social. Elise seems to be deviating from a number of accepted social norms.  Firstly, she is wearing a nightie despite being out of doors, this garment is usually something that you would only wear in bed and therefore if she is literally not wearing anything else i.e. no shoes or underwear this would make her very conspicuous and likely to draw negative attention from others. Elise also is muttering under her breathe. Speaking out loud in this way again breaches an unwritten rule for social behaviour. When a person’s behaviour breaches social norms, people often use this to make a dispositional judgement about that person, they are clearly not behaving in a certain way simply due to the behaviour being elicited by the situation, as they are in fact acting counter to expectation. Therefore, people often assume their behaviour must be indicative of some issue residing within the person, e.g. a psychiatric disorder. This means social deviance may be helpful in assessing Elise. However, many psychologists would argue that this alone is completely insufficient. Some students might have a more “avant garde” style of dress due to personal preferecnes, e.g. art /fashion students may choose to wear more unusual attire. Similarly, depending on Elise’s cultural/religious background her mantra/prayer may not be deemed unusual at all, likewise she may be rehearsing lines for a play, thus simply because behaviour may appear to breach one’s own socio-cultural expectations, the behaviour needs to be judged with good knowledge of the person in question and his or her own cultural background as opposed to the constraints of the cultural niche in which they currently find themselves. This said in Elise’s case there are other indicators as well as social deviance that indicate a possible diagnosis may be helpful.

The fact that she appears terrified and distraught indicates that she also fits the criterion for another D, distress. Had she not seemed so emotional one might assume that her behaviour (being out late at night alone, in unusual state of undress and muttering ) could possibly be some sort of eccentricity, and as such, be relatively harmless. In Elise’s case she is clearly suffering and this is one of Rosenhan and Seligman’s features that relate to dysfunction. This said, it should not be assumed that someone has to appear outwardly distressed in order to need a diagnosis. People with psychotic disorders may show no insight into their condition and may not be distressed by their condition. In Elise’s case however she does seem to combine both deviance and distress.

We mentioned dysfunction briefly and it would appear that Elise may be said to be dysfunctioning. Being out late and alone and in her current state of undress suggest that she is not functioning well, e.g. she has not considered the possible consequences, e.g. she might attract unwanted sexual attention, due to her inappropriate attire, which on its own could be a cause for her arrest. Also if it is late, she should either be having fun with friends or at home in bed. Wandering around on her own could be seen as dysfunctional although it is possible that onlookers simply do not understand the function that this behaviours serves for Elise. She may wander on her own and say her prayer/mantra for stress relief however again the fact that this is combined with her distress and inappropriate state of dress seem reasonable grounds to be considering a some form of support may be necessary to help her. If it is late at night, Elise may also find it hard to wake up in the morning and although the walk may seem helpful to her in the short term if this becomes a habit it could impact her ability to wake up , get up and go to her lectures each day and therefore it becomes a maladaptive behaviour assuming Elsie actually wants to be at university and pass her degree.

The final D is danger and again it would appear that Elise has potentially put herself in danger. She could catch a cold or be at risk of arrest due to her state of undress. More worryingly though, her extreme distress could mean that she is a risk to herself if she is distraught she may not be focusing on hazards around her which could be very dangerous if she is near traffic, water or heights. The most vivid aspect of the scenario however is that she says she believes her thoughts are being controlled. This is a phrase which certainly seems to deviate from the norm, people do not normally say such things indicating a genuine need for support. Although it could be argued that if Elise is from a different cultural group to the psychiatrist or her friends, some people do use language in more metaphoric ways and so unusual turn of phrase may not necessarily be indicative of disorder. In this case the worry for Elise is more related to who she is saying is controlling her thought s (a terrorist organisation) and that she is being told to harm her friends. This suggests that she may not only be a danger to herself but also to others. This suggests that some relatively immediate form of assistance may be necessary as she is fearful that she is a risk to others and this is the source of her distress. However, again it should be noted that danger to others may not be indicative of an underlying disorder, i.e. the person may be violent but not mentally disordered however in Elise’s case there are several other factors which add up to suggest that she may be need a diagnosis. However, the fact that she seems to be suffering from one clear cut symptom of schizophrenia, thought insertion, should not be taken on its own as an indication that she needs a diagnosis. Diagnoses should not be made on single symptoms and also it is important to know how long (duration) Elise has had these thoughts before a diagnosis is considered.

In conclusion, it would appear that none of the 4Ds on their own are enough to decide that a diagnosis may be necessary as apparent deviance may be due to a misunderstanding of differing socio-cultural norms, dysfunction can be seen to be very subjective and onlookers may not be aware of the function that an unusual behaviour in fact serves for that person and their standards and aspirations may not be the same as people around them, meaning they may appear dysfunction when they are not. The Ds of danger and distress are particularly helpful when making decisions in order to protect people from harm. However again it should be recognised that harm is subjective and just because a person may not appear at immediate risk, long term harm may occur without being detected by others and similarly a person does not have to be distressed by their actions, if the actions cause distress to sufficient others, this may be enough to require a diagnosis. However, yet again dependent upon the socio-cultural match between the individual and other others, it is possible that the others may perceive certain behaviours as troublesome when this may not be really the case. All in all the 4Ds need to be used in conjunction with each other and with a healthy dose of clinical judgement and knowledge of the person and their socio-cultral background.