Deja Review Behavioral Science, Second Edition

Transcription

TM
DEJA REVIEW
Behavioral Science
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TM
DEJA REVIEW
Behavioral Science
Second Edition
Gene R. Quinn, MD, MS
Resident Physician
Department of Medicine
University of California, San Francisco
San Francisco, California
University of Washington School of Medicine
Seattle, Washington
Class of 2009
New York Chicago San Francisco Lisbon London Madrid Mexico City
Milan New Delhi San Juan Seoul Singapore Sydney Toronto
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To my family
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Contents
Faculty Reviewers/Student Reviewers
Preface
SECTION I
xi
xiii
HUMAN DEVELOPMENT AND PSYCHOLOGY
1
Chapter 1
EARLY STAGES OF LIFE: INFANCY TO CHILDHOOD
Theories of Development / 3
Infant Morbidity and Mortality / 5
Neonatal Reflexes / 5
Developmental Milestones / 6
Attachment / 11
Early Adolescence (11 to 14 Years) / 12
Clinical Vignettes / 13
3
Chapter 2
MIDDLE STAGES OF LIFE: ADOLESCENCE TO ADULTHOOD
Early Adulthood / 15
Middle Adulthood / 17
15
Chapter 3
LATE STAGES OF LIFE: AGING, DEATH, AND BEREAVEMENT
Aging / 19
Dying, Death, and Bereavement / 21
19
Chapter 4
PSYCHOANALYTIC THEORY
25
Chapter 5
LEARNING THEORY
Associative Learning vs Nonassociative Learning / 35
35
Chapter 6
SLEEP SCIENCE AND DISORDERS
Normal Sleep / 43
Abnormal Sleep / 45
Other Sleep Changes / 47
43
viii
Contents
Chapter 7
SEXUALITY
Sexual Development / 49
Sexual Development and Physiologic Abnormalities / 50
Hormones and Their Influence on Behavior / 51
Sexual Response Cycle / 51
Sexual Dysfunction / 52
Paraphilias / 54
Influence of Medical Conditions on Sexuality / 54
Effects of Drugs and Neurotransmitters on Sexuality / 55
49
Chapter 8
ABUSE AND AGGRESSION
Children and Elder Abuse and Neglect / 57
Domestic Partner Abuse / 60
Sexual Violence / 61
Aggression / 62
57
Chapter 9
SUICIDE
Suicide / 65
65
Chapter 10
GENETIC BASIS OF BEHAVIOR
Genetic Studies / 69
Psychiatric Disorders Genetics / 69
Neuropsychiatric Disorder Genetics / 71
Alcoholism Genetics / 72
69
Chapter 11
NEUROCHEMISTRY IN BEHAVIORAL SCIENCES
Neuroanatomy / 75
Brain Lesions / 76
Neurotransmitters / 77
Amines / 78
Neuropeptides / 81
75
SECTION II
PSYCHIATRIC DISORDERS AND TREATMENT
83
Chapter 12
PSYCHOTIC DISORDERS
Introduction / 85
Disorders / 85
85
Contents
ix
Chapter 13
MOOD DISORDERS
93
Chapter 14
ANXIETY DISORDERS
Panic Disorder / 104
Obsessive-Compulsive Disorder / 105
Social Phobia / 106
Posttraumatic Stress Disorder / 107
Specific Phobia / 108
Adjustment Disorder with Anxiety / 109
103
Chapter 15
COGNITIVE DISORDERS
Delirium / 111
Dementia / 112
Amnestic Syndromes / 115
111
Chapter 16
SOMATOFORM DISORDERS
Somatization Disorder / 118
Conversion Disorder / 119
Hypochondriasis / 120
Body Dysmorphic Disorder / 121
Factitious Disorder / 122
Malingering / 123
117
Chapter 17
PERSONALITY DISORDERS
Cluster A: The Mad / 126
Cluster B: The Bad / 127
Cluster C: The Sad / 130
125
Chapter 18
DISSOCIATIVE DISORDERS
135
Chapter 19
SUBSTANCE ABUSE DISORDERS
139
Chapter 20
EATING DISORDERS
153
x
Contents
Chapter 21
CHILD PSYCHIATRY
Pervasive Development Disorders / 159
Disruptive Behavior Disorders / 161
Attention-Deficit Hyperactivity Disorder / 162
Other Neuropsychiatric Disorders of Childhood / 162
159
Chapter 22
PSYCHOPHARMACOLOGY
165
ETHICS, HEALTH CARE, AND STATISTICS
175
Chapter 23
CLINICAL PRACTICE AND DIFFICULT SITUATIONS
177
Chapter 24
MEDICAL ETHICS AND LEGAL ISSUES
181
Chapter 25
HEALTH CARE IN THE UNITED STATES
Health-Care Insurance / 191
Health-Care Costs / 193
Health-Care Delivery Systems / 194
Health Status and Determinants / 195
191
Chapter 26
EPIDEMIOLOGY AND RESEARCH DESIGN
Epidemiology / 199
Research Study Designs / 201
Testing / 203
Measures of Association / 205
199
Chapter 27
BIOSTATISTICS
Statistical Distribution / 209
Statistical Hypothesis and Error Types / 212
Statistical Tests / 214
209
Index
217
SECTION III
Faculty Reviewers
Debra L Klamen, MD, MPHE
Associate Dean, Education and Curriculum
Professor and Chair, Department of Medical
Education
Southern Illinois University School of
Medicine
Springfield, Illinois
Student Reviewers
Jessica Bury
Daniel Marcovici
Mayo Medical School
MD/MPH Candidate
Class of 2010
Sackler School of Medicine
Tel Aviv University
Class of 2011
Sarah Fabiano
SUNY Upstate Medical University
Class of 2010
Preface
Behavioral science is an extremely high-yield, yet often overlooked, subject on the
USMLE Step 1. Understanding important behavioral science concepts and being able
to apply them to test questions can significantly increase your score. Deja Review:
Behavioral Sciences is the perfect format to study behavioral science material; it helps
you rapidly review material you know as well as fill-in gaps in your knowledge.
In this second edition of Deja Review: Behavioral Sciences I have highlighted high-yield
concepts such as psychiatric disorders and developmental milestones while still keeping
the content comprehensive enough to use during your preclinical course and clerkship.
Epidemiology and biostatistics are often tested on the USMLE—this new edition has
fully revised and expanded sections on these subjects that will review and teach you
core concepts needed to work through epidemiology questions on the USMLE. With a
little bit of work and Deja Review: Behavioral Sciences, you’ll be well-prepared for the
multitude of behavioral science questions on the USMLE.
ORGANIZATION
All concepts are presented in a question and answer “flashcard” format that covers key
facts on commonly tested topics in behavioral medicine. Behavioral science is often
conceptual, and questions are designed to review and teach these concepts instead of
simply memorizing material.
The question and answer format has several important advantages:
• It provides a rapid, straightforward way for you to assess your strengths and
weaknesses.
• It serves as a quick, last-minute review of high-yield facts.
• It allows you to efficiently review and commit to memory a large body of
information.
At the end of each chapter, you will find clinical vignettes that expose you to the type
of questions classically tested on the USMLE Step 1. These board-style questions put
the basic science into a clinical context, allowing you apply the facts you have just
reviewed in a clinical scenario and make the diagnosis.
HOW TO USE THIS BOOK
This text was assembled with the intent to represent the core topics tested on course
examinations and USMLE Step 1. Remember, this text is not intended to replace comprehensive textbooks, course packs, or lectures. However, it may serve as a supplement
xiv
Preface
to your studies during your coursework and Step 1 preparation. You may use the book
to quiz yourself or classmates on topics covered in recent lectures and clinical case discussions. A bookmark is included so that you can easily cover up the answers as you
work through each chapter. The compact, condensed design of the book is conducive
to studying on the go, especially during any downtime throughout your busy day.
However you choose to study, I hope you find this resource helpful throughout your
preparation. Good luck and good studying!
Gene R. Quinn
SECTION I
Human Development
and Psychology
CHAPTER 1
Early Stages of Life:
Infancy to Childhood
THEORIES OF DEVELOPMENT
Describe Erik Erikson’s theories of
development.
Critical periods at which achievement
of social goals need to be achieved,
otherwise they won’t be achieved.
Describe Sigmund Freud’s theories of
development.
Organized by parts of the body from
which pleasure is derived at each age of
development. Each stage is part of the
development into the sexual maturity of
adulthood, characterized by ego
formation and the ability to delay
gratification.
Describe Jean Piaget’s theories of
development.
Learning capabilities of the child at
various ages during development;
children must move through four stages
of development. There is a specific set
of skills that must be mastered at each
stage of development before
progression to the other stages.
Erik Erikson’s Theory of Development
Which stage of development is
characterized by an infant establishing
faith in their caregiver?
Trust vs Mistrust: birth to 18 months
characterized by a child learning
physical skills such as walking and
learning to use the bathroom?
Autonomy vs Shame and Doubt:
age 18 months to 3 years
characterized by a child becoming
assertive in their learning?
Initiative vs Guilt: age 3 to 6 years
3
4 Deja Review: Behavioral Science
characterized by a child acquiring
new skills at a rapid rate?
Industry vs Inferiority: age 6 to 12 years
characterized by a teen who achieves a
sense of identity in politics, sex roles,
or occupation?
Identity vs Role Confusion: age 12 to
18 years
characterized by an adult determining
whether or not they want to establish
an intimate relationship with another
individual?
Intimacy vs Isolation: age 19 to 40 years
characterized by an adult finding ways
to support and encourage the next
generation?
Generativity vs Stagnation: age 40 to
65 years
characterized by an adult reflecting
on their experiences to derive
meaning from their life?
Ego Integrity vs Despair: age 65 years
to death
Sigmund Freud’s Theory of Development
characterized by focus on receiving
pleasure through food consumption or
sucking on pacifiers?
Oral phase present from birth to
age 1 year
characterized by focus on receiving
pleasure through potty training?
Anal phase present from age 1 to
3 years
characterized by focus on identifying
with adult role models and the oedipal
complex?
Phallic phase present from age 3 to
6 years
characterized by focus on expanding
social interactions?
Latency phase present from age 6 to
12 years
characterized by focus on establishing
a family?
Genital phase present from age 13 to
adulthood
Jean Piaget’s Theory of Development
characterized by infants and toddlers
focusing on their eyes, ears, hands,
and other senses?
Sensorimotor period from birth to
age 2 years
Early Stages of Life: Infancy to Childhood 5
characterized by children acquiring
representational skills in the area of
mental imagery and language?
Preoperational thought present from
age 2 to 7 years
characterized by children being more
logical, flexible, and organized than in
early childhood?
Concrete operational present from
age 7 to 12 years
characterized by being able to think
logically, theoretically, and abstractly?
Formal operational from age 12 to
adulthood
INFANT MORBIDITY AND MORTALITY
Define premature birth.
Less than 34 weeks gestation or birth
weight less than 2500 g
What are the potential outcomes of
being a premature infant?
Increased infant mortality
In the United States, what percentage
of births is premature?
6% for white women and 13% for
African American women (an average
of 7.2 per 1000 live births)
What are the common risk factors
associated with premature births?
Low socioeconomic status
Teenage pregnancy
Delayed physical and social development
Emotional and behavioral problems
Dyslexia
Child abuse
Poor maternal nutrition
NEONATAL REFLEXES
What are the six important neonatal
reflexes?
1.
2.
3.
4.
5.
6.
Moro
Palmar grasp
Rooting
Stepping
Asymmetric tonic neck
Parachute
Which neonatal reflexes are present
at birth?
Moro
Palmar grasp
Rooting
Stepping
What is the Moro/”startle” reflex?
Head extension causes extremity
extension followed by flexion.
What is the palmar grasp?
If a finger is placed in an infant’s palm,
it is grasped.
What is the rooting reflex?
If an object is placed around an infant’s
mouth, the infant will pursue it.
What is the stepping reflex?
When held upright and leaning
forward, an infant will make walking
motions with their legs.
At what age do the Moro,
palmar, rooting, and stepping
reflexes disappear?
4 to 6 months
What is the asymmetric tonic neck?
While supine, turning of the head
causes ipsilateral extremity extension
and contralateral flexion.
At what age does asymmetric tonic
neck appear and then disappear?
Present at 2 weeks and disappears
by 6 months
What is the parachute reflex?
While sitting and tilted to one side, an
infant extends the ipsilateral arm to
support the body.
DEVELOPMENTAL MILESTONES
What are the key categories of
development?
Gross motor
Fine/visual motor
Language
Social
What are the developmental milestones
at 1 month of age?
Gross motor: when prone lifts head
slightly
Fine/visual: with eyes tracks objects to
midline; tight grasp
Language: startles to sound
Social: fixes on face
at 2 to 3 months of age?
Gross motor: steadily holds head up;
when prone lifts chest up
Fine/visual: hands open at rest
Language: smiles responsively; coos
Social: recognizes parents; reaches for
familiar objects or people
at 4 to 5 months of age?
Gross motor: rolls front to back and back
to front; sits well supported
Fine/visual: grasps with both hands
Language: orients to voice
Social: laughs; enjoys observing
environment
at 6 months of age?
Gross motor: sits well unsupported; sits
upright
Fine/visual: transfers hand to hand;
reaches with either hand
Language: babbles
Social: recognizes strangers and has
stranger anxiety
at 9 months of age?
Gross motor: crawls, pulls to stand
Fine/visual: uses pincer grasp; finger
feeds
Language: says “dada/mama”;
understands “no”
Social: waves bye-bye; plays
pat-a-cake
at 12 months of age?
Gross motor: walks alone
Gross motor: walks backward; creeps
upstairs
Fine/visual: throws, releases objects
Language: one to eight words other
than “dada/mama”; one-step
commands
Social: imitates actions; comes when
called; cooperates with dressing
Fine/visual: builds two-block towers;
scribbles; uses a cup
Language: uses four to eight words
Social: throws temper tantrums
Gross motor: runs; kicks a ball
Fine/visual: feeds self with utensils
Language: points to body parts
when asked; names common
objects
Social: plays around but not with other
children; start of toilet training
Gross motor: squats and recovers
Fine/visual: builds five-block towers
Language: two-word combinations
Social: toilet training
Gross motor: walks well up and down
stairs; jumps
Fine/visual: removes clothing; copies a
line
Language: 50-word vocabulary;
stranger understands half of
speech
Social: follows two-step commands;
engages in parallel play
Gross motor: throws ball over hand
at 3 years of age?
Gross motor: pedals tricycle; goes
up and down stairs with alternating
feet
Fine/visual: removes clothes; copies
lines
Language: appropriate pronoun use
Social: knows first and last names
Fine/visual: draws a circle; eats with
utensils
Language: three-word sentences;
uses plurals and past tense;
stranger understands three-fourths
of speech
Social: group play; shares toys
at 4 years of age?
Gross motor: hops and skips
Fine/visual: catches ball; dresses alone;
copies a cross
Language: knows colors; counts to 10
Social: imaginative play
at 5 years of age?
Gross motor: hops and skips
Fine/visual: ties shoes
Language: prints first name
Social: plays cooperative games;
understands rules and abides by them
Table 1.1 Developmental Milestones
Gross
Motor
Fine/Visual
Motor
Language
Social
1 month old
When
prone lifts
head
slightly
With eyes
tracks
objects to
midline;
tight grasp
Startles to
sound
Fixes on face
Hands open
at rest
Smiles
responsively;
coos
Recognizes
parents;
reaches for
familiar
objects or
people
Grasps
with both
hands
Orients to
voice
Laughs;
enjoys
observing
environment
Sits well
unsupported;
sits upright
Transfers
hand to
hand;
reaches with
either hand
Babbles
Recognizes
strangers
and has
stranger
anxiety
Crawls,
pulls to
stand
Uses pincer
grasp;
finger
feeds
Says
Waves
“dada/mama”; bye-bye;
understands
plays
“no”
pat-a-cake
Throws,
releases
objects
One to eight
words other
than “dada/
mama”;
one-step
commands
2 to 3 months old
Steadily holds
head up;
when prone
lifts chest
up
4 to 5 months old
Rolls front to
back and
back to front;
sits well
supported
6 months old
9 months old
12 months old
Walks alone
Imitates
actions;
comes when
called;
cooperates
with
dressing
(Continued)
Table 1.1 Developmental Milestones (Continued )
Gross
Motor
15 months old
Walks
backward;
creeps
upstairs
Fine/Visual
Motor
Language
Social
Builds twoblock
towers;
scribbles;
uses a cup
Uses four to
eight words
Throws
temper
tantrums
Feeds self
with
utensils
Points to body
parts when
asked; names
common
objects
Plays around
but not with
other
children;
start of
toilet
training
21 months old
Squats
and
recovers
Builds
five-block
towers
Two-word
combinations
Toilet
training
24 months old
Walks well
up and
down stairs;
jumps
Removes
clothing;
copies a
line
50-word
vocabulary;
stranger
understands
half of speech
Follows twostep
commands;
engages in
parallel
play
Removes
clothes;
copies
lines
Appropriate
pronoun use
Knows first
and last
names
Draws a
circle; eats
with
utensils
Three-word
sentences;
uses plurals
and past
tense;
stranger
understands
three-fourths
of speech
Group play;
shares toys
18 months old
Runs; kicks a
ball
30 months old
Throws ball
over hand
3 years old
Pedals
tricycle;
goes up
and down
stairs with
alternating
feet
Table 1.1 Developmental Milestones (Continued )
Gross
Motor
Fine/Visual
Motor
Language
Social
4 years old
Hops and
skips
Catches
ball;
dresses
alone;
copies a
cross
Knows colors;
counts to 10
Imaginative
play
Hops and
skips
Ties shoes
Prints first
name
Plays
cooperative
games;
understands
rules and
abides by
them
5 years old
ATTACHMENT
What is anaclitic depression?
Physical, psychological, and social
problems caused by prolonged removal
of parental nurturing during ages 6 to
12 months. This is reversed if nurturing
is reintroduced.
What occurs without proper
mothering or attachment?
Failure to thrive
What occurs during failure
to thrive?
Developmental retardation
Poor health and growth
High death rates, even with adequate
physical care
Toddlers who are hospitalized
are most likely to fear what?
Separation from parents or care
providers more than bodily harm or
pain
In what age group is elective
surgery best tolerated?
7 to 11 years
By age 3, how does separation from
parents or care providers affect
children?
Separation from parents has no
long-term negative effects on children.
In fact, children at age 3 are able to
spend significant portions of the day
with other adults.
How do toddlers understand death?
It is an incomplete understanding of the
meaning of death and the child may
expect a friend, relative, or pet to come
back to life.
At what age do children begin to
understand the concept of death?
At the age of 8 years
In what age group do children
begin to form relationships with
other adults?
7 to 11 years
At what point should adopted
children be told that they
are adopted?
At the earliest age possible, when they
are able to understand language
EARLY ADOLESCENCE (11 TO 14 YEARS)
How is the start of puberty marked?
In girls: the onset of menstruation,
beginning at age 11 to 12 years
In boys: the first ejaculation, occurring at
age 13 to 14 years
How is the development through
puberty measured?
By the Tanner stages
How many Tanner stages are there?
There are five Tanner stages.
What are the three categories of
measurement?
1. Male genitalia
2. Female breasts
3. Pubic hair
Table 1.2 Tanner Stages of Development
Male Genitalia
Female Breasts
Pubic Hair
Stage I
Childhood-sized
penis, testes, and
scrotum
Preadolescent breasts
with elevation of the
papilla only
Absent.
Enlargement of the
testes and scrotum
Breast buds with
elevation of breast
and papilla
Pubic hair is
sparse and
straight with
downy hair on
labia/penis base.
Penis enlargement
Breast and areola
enlargement with
ingle contour
Pubic hair is
curled, darker,
and coarse.
Scrotal skin
darkening and
rugations are
present.
Areola and papilla
projection with
separate contour
(secondary mound).
Pubic hair is
adult- type hair
limited to the
genital area.
Adult-sized and
-shaped penis,
testes, and scrotum
Mature breasts
Pubic hair is
adult-quantity
and -pattern and
spreads to the
thighs.
Stage II
Stage III
Stage IV
Stage V
CLINICAL VIGNETTES
A worried mother brings her 6-month-old son to your office for a checkup. She
states that his highest achieved milestones are: he can recognize strangers, wave
bye-bye, use a pincer-grasp, smile responsively, coo, crawl, and pull to stand. In
which developmental areas is he behind?
He is delayed in his language skills. By 6 months he should be babbling, and he
should have oriented to voice before that. His language skills are that of a 2-3month-old. His gross motor, fine motor, and social skills are all at a 9-month level.
Your medical school classmate is a braggart; he loves to tell everyone how
advanced his 12-month-old daughter is. He claims she can walk backward, uses a
cup, builds a two-block tower, uses six different words, and throws the cutest
temper tantrums you’ve ever seen. How far advanced is she in developmental
milestones?
She is at a 15-month level in all areas—fine motor, gross motor, language, and
social.
A 35-year-old-male patient comes to your office worried that he never finished
going through puberty. His pubic hair is sparse, but it is dark and curled. His penis
has enlarged, but there is no scrotal darkening or rogations. At what Tanner stage
is he?
Tanner stage III
CHAPTER 2
Middle Stages of Life:
Adolescence to
Adulthood
EARLY ADULTHOOD
What age range constitutes early
adulthood?
20 to 40 years
What are the primary characteristics
of this stage of life?
Role in society is defined.
Physical development peaks.
Sense of independence.
Which Erikson stage is prevalent
during early adulthood?
Intimacy vs Isolation
Which life events often occur during
this stage?
Marriage
What percentage of Americans is
married by age 30?
60% to 70%
What are postpartum blues?
Mild mood swings that may switch
quite rapidly and occur after delivery—
usually within a few days.
What is the percentage of women who
suffer from postpartum blues?
40% to 80% (very common and
considered normal)
How long do the symptoms of
postpartum blue last?
They usually resolve within 2 weeks.
Having children
Occupation
15
What can a physician do to assist
a patient with postpartum blues?
Support and reassurance
Advise to get help with child care
Watch for development of postpartum
depression
What is the percentage of women who
suffer from postpartum depression?
5% to 25% (making it important to
screen for!)
What are the diagnostic criteria for
postpartum major depression?
The same as a major depressive episode,
but occurring after delivery.
Note: The Diagnostic and Statistical
Manual of Mental Disorders, fourth edition
(DSM-IV-TR) does not have a separate
diagnosis for postpartum depression—
only a “postpartum onset” modifier of
major depression.
What complications for the mother/
child relationship may result from
postpartum depression?
Failure to form bond with the baby
Thoughts of failure as a mother
Feeling unable to take care of baby
Interference with child development
Suicide of mother or homicide of infant
When do the symptoms of postpartum
major depression occur?
Within 4 weeks after delivery (DSM-IV-TR
criteria for “postpartum onset”), though
some say up to 12 months after
What can a physician do to assist a
patient with postpartum major
depression?
Psychosocial therapy
Antidepressant medication
May require hospitalization if severe
What percentage of women suffer from
postpartum psychosis?
0.1% to 0.2%
What are characteristics of postpartum
psychosis?
Delusions
Hallucinations
Mother may harm infant
When do the symptoms of postpartum
psychosis occur?
2 to 3 weeks after delivery
What can a physician do to assist a
patient with postpartum psychosis?
Antipsychotic medication
Hospitalization
Note: This is a psychiatric emergency!
Which postpartum emotional reaction
is considered normal?
Postpartum blues
Middle Stages of Life: Adolescence to Adulthood 17
MIDDLE ADULTHOOD
What age range constitutes middle
adulthood?
40 to 65 years
What are the primary characteristics of
this stage of life?
Power
Which Erikson stage is prevalent during
middle adulthood?
Generativity vs Stagnation
What term describes the decrease in
physiologic function that occurs
in midlife?
Climacterium
What physiologic functions decrease
in men?
Endurance
Authority
Muscle strength
Sexual performance
What major reproductive change occurs
in women?
Menopause
What are the characteristics of
menopause?
Lack of menstrual cycles
Hot flashes
Sexual Dysfunction/Vaginal Dryness
Osteoporosis (long-term)
What medical intervention has been
used to treat acute menopausal
symptoms?
Short-term estrogen replacement
therapy (long-term not recommended)
How long should contraceptive
measures continue after the
last menstrual period in
menopause?
1 year
CLINICAL VIGNETTES
A woman who delivered a healthy baby boy 4 days ago comes into your clinic. She
states that she has been having mood swings—sometimes laughing, sometimes
crying. She feels it is impacting her care of her baby.
What is the most likely diagnosis?
Postpartum blues
What should your treatment be?
You should screen her for postpartum depression and stay vigilant for this
diagnosis—but reassure her that her symptoms are normal and will likely resolve
within a couple of weeks. Also, recommend that she have someone help her with
child care. Be sure to distinguish this from postpartum depression—a common
disorder with more severe symptoms that should be treated more aggressively.
A 58-year-old woman complains of less interest in sex over the last few years. She
says it is a combination of less desire and pain with intercourse. What is the most
likely cause of the patient’s symptoms?
Postmenopausal women have a significant decrease in estrogen, leading to vaginal
atrophy, dryness, and sexual dysfunction. Topical vaginal estrogen preparations
may help, as can lubricants.
A 32-year-old married woman develops hallucination and delusions 2 weeks after
the delivery of a healthy baby boy. She informs the physician that she has had
thoughts about harming the infant. The physician decides to hospitalize the
mother immediately and place her on antipsychotic medication. What postpartum
reaction has the woman experienced?
Postpartum psychosis
CHAPTER 3
Late Stages of Life:
Aging, Death, and
Bereavement
AGING
What percentage of the US population
will be 65 years and older by the
year 2020?
15%
Which is the fastest growing age group
in the United States today?
85 years and older
What is the average life expectancy in
the United States?
77 years
What factors within a population can
have an effect on differences in life
expectancy?
Gender (females tend to live longer than
males; an average difference of 7 years)
How are the life expectancies changing
in regard to different ethnic groups?
Males and African Americans are living
longer, thus the gap between them and
the longest living (white female) is
decreasing.
What physical changes are associated
with aging?
Sensory: impaired vision and hearing
Visceral: decreased pulmonary, renal,
and gastrointestinal function
Extremities: increased fat deposits,
osteoporosis, and decreased muscle
mass and strength
Race (whites tend to live longer than
blacks)
White female (80 years) > black female
(74 years) = white male (74 years) >
black male (66 years)
19
What changes in the brain usually
accompany aging?
Less cerebral blood flow
Decreased brain weight
Enlarged ventricles and sulci
Increased amount of senile plaques and
neurofibrillary tangles (also found in
older brains from patients who did not
suffer from Alzheimer disease [AD])
Psychological
Does an individual’s level of
intelligence change throughout life?
No. Slight decreases in cognitive ability
are usually compensated for by life
experience and wisdom—so called
“crystallized intelligence.”
Which Erikson stage of development
is characteristic of the last stage of life?
Ego Integrity vs Despair. During this
time there is an evaluation of the choices
made in one’s life and a reconciliation
of those choices with one’s values. A
positive evaluation leads to contentment,
whereas a negative evaluation leads to
discontent.
Psychopathology
What is the most common psychiatric
illness of the elderly?
Major depression
What factors can lead to depression in
the elderly?
Loss of spouse, friends, and/or family
Loss of prestige and income
Decline of health
Retirement
What common disease process involving
cognitive decline may mimic depression
in the elderly?
Dementia
What three methods can be used to
successfully treat depression?
1. Pharmacotherapy
2. Psychotherapy
3. Electroconvulsive therapy (this is
still the most effective treatment for
depression)
What changes in sleep patterns occur
in the elderly?
Decreased quality of sleep with less
time in deep sleep and more time in
light sleep
Decreased rapid eye movement (REM)
sleep
Late Stages of Life: Aging, Death, and Bereavement 21
What substance-use disorders are
common in the elderly population but
often unidentified?
Alcohol-related disorders
Do psychiatric drugs produce the same
effects in the elderly as they do in
young adults?
No. There are differences in drug
bioavailability, metabolism, and
response, and the elderly have a greater
susceptibility to side effects. Therefore,
when you prescribe, you should start
low and go slow.
Longevity
What factors are associated with
longevity?
Family history of longevity
Continuation of occupational and
physical activity
Higher education
Social support system including marriage
(only men benefit from marriage)
DYING, DEATH, AND BEREAVEMENT
Which author describes five stages of
death and dying, which may or may
not occur in consecutive order?
Elizabeth Kubler Ross
At what stage would a patient refuse
to believe he or she is dying and say,
“You must be reading the
wrong chart”?
Denial
At what stage would a patient become
upset with the hospital staff and say,
“You should have made the diagnosis
sooner! It is your fault I am in this
situation”?
Anger
At what stage would a patient plead
with a higher power for forgiveness
and healing?
Bargaining
At which stage would a patient
become tearful, withdrawn, and
apathetic?
Depression
At what stage would a patient gain the
understanding that life has come to
an end?
Acceptance
What is the difference between
bereavement and major depression?
Bereavement tends to be less severe
in symptoms and less pervasive
(ie, centers only around the loss).
It is also self-limited and has a shorter
duration.
However, major depressive episodes
may be superimposed onto, or
precipitated by a major loss with
bereavement.
How long does bereavement last?
Normal bereavement should begin to
resolve within a few months, though
some grief may never go away.
A DSM-IV-TR diagnosis of major
depression should not be made within
the first 2 months after a loss.
Table 3.1 Differences Between Bereavement (Normal Grief) and Major Depression
(Abnormal Grief)
Bereavement
Depression
Minor sleep disturbances
Major sleep disturbances
Some feelings of guilt
Feeling of worthlessness
Illusions
Hallucinations and delusions
Expressions of sadness
Suicidal thoughts and attempts
Minor weight loss (<3 lb)
Major weight loss (>8 lb)
Good grooming and hygiene
Poor grooming
Attempts to return to normal routine
Few attempts to return to normal
routine
Severe symptoms subside in
<2 months
Severe symptoms continue for
>2 months
Moderate symptoms subside in
<1 month
Moderate symptoms subside in
>1 month
Tx: support groups, increased
contact with physician, counseling,
short-acting sedatives if needed
Tx: may include antidepressants,
psychotherapy, antipsychotics,
and electroconvulsive therapy
Abbreviation: Tx, treatment.
Late Stages of Life: Aging, Death, and Bereavement 23
CLINICAL VIGNETTES
You diagnose a 53-year-old man who has a long history of heavy smoking with
metastatic lung cancer. What stage of grief would he likely be in if he:
Says “I’ll be fine,” and lights up another cigarette.
Denial
Goes to church and prays to live another 3 years, just long enough to see his
daughter graduate college.
Bargaining
Throws your reflex hammer at a nurse.
Anger
Says “I don’t care—there’s no point in living anyway.”
Depression
Starts to make plans for his hospice care and his surviving family.
Acceptance
An 83-year-old man lost his wife to cancer 1 month ago. He feels sad all the time,
always thinking about his wife. He cries at night and cannot sleep. He has not
been doing any of his normal activities. He also believes he hears his wife
whispering in his ear at night before bedtime. What is your diagnosis?
Bereavement—symptoms have only been present for 1 month after a major loss.
If symptoms were to become more severe and last over 2 months, he would need
to be screened for a mood disorder using DSM-IV-TR criteria.
A 76-year-old man finds that he has left little impact on the world. He did not
spend much time with his children, he is divorced, and he is not happy with any
of the big decisions in his life. Which Erickson stage of life is this man most likely
experiencing?
Ego Integrity vs Despair
CHAPTER 4
Psychoanalytic
Theory
What are the two major theories of the
mind developed by Freud?
1. Topographic theory of the mind
(includes three parts):
a. Conscious
b. Preconscious
c. Unconscious
2. Structural theory of the mind
(also known as the tripartite
theory):
a. Ego
b. Superego
c. Id
Which part of Freud’s topographic mind
contains information that one is
unaware of, but can be accessed
with prompting?
Preconscious
Which part of the mind contains
thoughts of which a person is aware?
The conscious—this part of the mind has
no access to the unconscious. The
unconscious includes what we are not
aware of such as sexual drives,
aggressive drives, impulses, or
fantasies.
How is the expression of the id
regulated?
The ego exerts the learned rules of the
world over the id to control its overt
expression of primitive drives, such as
sexual urges and aggression. The ego
manages and negotiates the drives from
the id as well as moral restrictions (from
the superego).
Which part of the mind helps a person
maintain relationships?
The ego
25
Which part of the mind incorporates
acquired moral and ethical concepts?
The superego (our conscience)
How does the ego deal with conflicts
between the id and the superego?
Defense mechanisms
What type of thinking is primary
process?
It is associated with pleasure and
instincts. This process does not involve
logic or time and may not be linear.
Which part of the mind is controlled
by primary process thinking?
The id—this is not influenced by reality
and focuses on pleasure and instinct
(primary processes).
What is psychotherapy?
A treatment technique. This treatment
ranges from strengthening useful ego
defenses (in supportive therapy) to
challenging detrimental ego defenses
and uncovering unconscious conflicts
(in expressive and analytic
psychotherapy), improving self-esteem,
and improving relationships.
What is the purpose of psychotherapy?
To improve functionality. It helps to
support defenses and functioning,
reduce anxiety/stress, work on specific
conflicts, improve coping skills, have
healthier relationships, and enhance
enjoyment/fulfillment in life.
What are the differences between
psychodynamic psychotherapy and
psychoanalysis?
Time:
• Psychoanalysis: 1 hour,
3 to 5 × per week for 3 to
8 years
• Psychotherapy: 1 hour,
1 to 2 × per week for 2 to
20 years
Level of therapist’s participation:
• Psychoanalysis: The therapist mainly
listens to the patient who lies on the
couch and helps guide the patient,
clarify, question, gently confront,
encourage, interpret, analyze,
and so forth.
• Psychodynamic: The therapist
is more interactive while both
he or she and the patient sit in chairs
facing each other, though the
therapist still plays a guiding role.
Psychoanalytic Theory 27
What are the three main
techniques used in psychoanalysis
and psychodynamic
psychotherapy to uncover
the unconscious?
1. Free association
2. Dream interpretations
3. Transference interpretations
Which technique is used to describe
the patient expressing “whatever
comes to mind”?
Free association
How does the unconscious mind
manifest impulses, wishes,
and fears?
Through dreams, slips of the tongue,
and forgetting significant things
What is the purpose of a defense
mechanism?
Maintaining the ego or decreasing
anxiety and maintaining a sense
of self
What are the mature defense
mechanisms?
Humor
Altruism
Sublimation
Suppression
What are the immature defense
mechanisms?
Acting out
Denial
Displacement
Dissociation
Fixation
Identification
Intellectualization
Isolation
Projection
Rationalization
Reaction formation
Regression
Repression
Splitting
Which defense mechanism causes a
patient to take his uncomfortable
feelings toward an unacceptable
target and aim it at a more acceptable
target?
Displacement
Which defense mechanism allows one
to use a socially acceptable way to
combat an unacceptable impulse?
Sublimation
How does sublimation differ from
displacement?
In displacement, the object or person
receiving the negative attention is
“more tolerable” to the individual
(kick dog instead of boss), while in
sublimation, the negative attention
is channeled into an activity that is
socially acceptable (vigorous
exercise to relieve stress caused
by boss).
to find amusement in an otherwise
difficult situation?
Humor
If a patient uses intellectualization
and isolation of affect as ways to
deal with their discomfort, what
personality disorder might
he have?
Obsessive-compulsive personality
disorder (OCPD)
What defense mechanisms are highly
associated with OCPD?
Intellectualization (focus on facts about
painful things instead of the painful
things—eg, learning about treatments
for cancer when diagnosed rather than
feeling grief over the diagnosis.)
Rationalization (making excuses that
seem like a reasonable explanation—eg,
I failed out of medical school because
I didn’t really like biology anyway.)
Isolation of affect (eg, I refuse to have
emotions about this topic because
emotions are too difficult.)
Reaction formation (eg, I can’t deal with
the fact that I hate you so I’ll give you a
gift instead.)
How does rationalization differ from
intellectualization?
Rationalization occurs when a person
uses excuses to explain an uncomfortable
feeling related to an event or person.
Intellectualization is when a person
defers to factual information in order to
deal with or understand uncomfortable
feelings.
Which immature defense is used
extensively by patients with borderline
personality disorder who cannot
integrate the good and bad aspects
of the same person?
Splitting
Which defense mechanism leads a
patient to deal with an uncomfortable
situation by “placing it on the back
burner”?
Suppression
How does repression differ from
suppression?
Repression is an immature defense
mechanism that occurs when the
unconscious causes us to “forget”
painful information while suppression
is a mature defense mechanism that
allows us to consciously put off painful
information and “deal with it later” in
order to maintain our composure.
Which defense mechanism is associated
with a person dealing with stressful
situations in a childlike manner?
Regression
In which personality disorder is
repression, regression, and
somatization used the most?
Histrionic
Which defense mechanism allows us to
place our bad feelings about ourselves
onto others?
Projection
How does displacement differ from
projection?
Displacement allows us to place our
negative emotion about someone else
onto another target, while projection
allows us to place our negative
emotions about ourselves onto another
target.
Which defense mechanism causes us
to take on the positive and negative
behaviors of others?
Identification
Which personality disorders use
projection and denial as their primary
defense mechanisms?
Paranoid personality disorder
Schizotypal personality disorder
Antisocial personality disorder
Borderline personality disorder
How does denial differ from splitting?
In denial, patients ignore all the bad
aspects about something entirely (Bob’s
dog died but he is still feeding him
every night). This is not a conscious
action. With splitting, patients cannot
see the positive and the negative at the
same time (their doctors are either
“horrible” or “wonderful” but never
“so-so”).
If a man “forgets” to return calls to all
of the clients he dislikes today, which
defense mechanism is at work?
Avoidance
Which two personality disorders
primarily utilize avoidance?
Avoidant and dependent personality
disorders
If a man who recently embezzled
money donates funds to a homeless
shelter, what defense mechanism is
he using?
Altruism—assisting others to avoid
feeling bad about oneself
Which defense mechanism causes an
individual to express unacceptable
thoughts and feelings in a socially
inappropriate manner?
Acting out
to avoid a painful situation by acting as
if it never happened?
Denial
What is the emotional reaction a patient
has toward their physician?
Transference. It occurs when patients
unconsciously reexperience relationships
from their past in their current
relationship. This can occur in any
relationship (not just with therapists or
physicians). It can be a useful tool in
therapy.
What is the emotional reaction a
physician has to a patient?
Countertransference. It has two parts:
1. Feelings the physician has toward
the patient that are related to their
own past (like transference).
2. Feelings that a physician has toward
the patient that resembles how the
patient causes most people to feel
(patient specific).
What are the merits of recognizing
countertransference?
The physician’s countertransference can
influence the way the patient is treated.
It is also a useful insight in psychotherapy
to recognize how the patient makes
others feel about them.
Mature
Table 4.1
31
Immature
Defense
Mechanism
Description
Altruism
Guilty feelings are alleviated by kindness to others
Humor
Recognizing the amusing nature of an anxiety-provoking or adverse situation
Sublimation
Channeling unacceptable impulses into acceptable actions
Suppression
Voluntary blocking of an idea or feeling from conscious awareness
Acting Out
Undesirable feelings and thoughts are expressed through actions
Denial
Refusing to accept facts about an unpleasant reality
Displacement
Transferring feeling about one thing to something else
Dissociation
Detaching from oneself; emotionally or mentally
Identification
Modeling one’s behavior after someone more powerful
Intellectualization
Using facts and logic to avoid emotions
Projection
Attributing one’s feelings to an external source
Rationalization
Proclaiming logical reasons for actions actually performed for other reasons
Reaction formation
Process whereby a warded-off idea or feeling is replaced by an unconsciously derived
emphasis on its opposite
Regression
Returning to a less mature stage of development
Repression
Involuntary blocking of an idea or feeling from conscious awareness
Splitting
Belief that people are either all good or all bad
(Continued)
Mature
Table 4.1 (Continued )
32
Immature
Defense
Mechanism
Example
Altruism
Criminal makes large donation to charity.
Humor
Nervous surgeon jokes about an upcoming procedure.
Sublimation
Aggressiveness used to succeed in business ventures.
Suppression
Choosing not to think about life stresses during work.
Acting Out
A teenager punches a hole in the wall.
Denial
An HIV-positive man adamantly states he is healthy.
Displacement
Mother yells at her child because she is angry at her husband.
Dissociation
Floating above one’s body during a traumatic event.
Identification
An abused child becomes a bully.
Intellectualization
A newly diagnosed cancer patient calmly describes the pathogenesis of their disease.
Projection
A woman who fantasizes about another man thinks her husband is cheating on her.
Rationalization
Saying a job was not important, after getting fired.
Reaction formation
A patient with sexual thoughts enters a monastery.
Regression
An adult clutching a sentimental teddy bear.
Repression
Traumatic childhood events remain buried in the unconscious.
Splitting
A patient says that all men are cold and insensitive but that women are warm and friendly.
CLINICAL VIGNETTES
A middle-aged woman is in a grocery store. She goes to the bulk candy section and
sees gummy bears—her favorite. Part of her mind says she should grab a handful
and stuff them in her mouth. Which part of the mind is telling her this?
The id
A man and a woman are in a car accident. Neither has insurance and both cars are
totaled, and both of them lose their licenses. The woman goes home and says
“Well, at least I wasn’t driving a Ferrari—that would have been much more
expensive.” The man says “I hit her because I was swerving to avoid something
else. I should have had my brakes balanced.” What defense mechanisms are they
using and are they mature or immature defenses?
The woman is using humor—a mature mechanism. The man is using rationalization—
an immature mechanism.
A medical student is mistreated by his professor, but later tells his fellow medical
students that the professor is “great”! What defense mechanism is he using?
Reaction formation
A medical student’s dog dies. When he is consoled by fellow students, he states,
“He was really old and I was expecting him to go soon anyway. Most large dogs
only live until they are 10.” What defense mechanism is he using?
Intellectualization
A medical student fails the last anatomy exam after he studied 12 hours per day in
the corner of the library for 1 month. He tells his friend, “I think I failed because
I didn’t study enough. Besides, I am not really going to use anatomy later on.”
What defense mechanism is he using?
Rationalization
CHAPTER 5
Learning Theory
It is a learning theory based on the idea
that behavior is a product of learning
through association or reinforcement.
What is behaviorism?
ASSOCIATIVE LEARNING VS NONASSOCIATIVE LEARNING
What is associative learning?
Learning that occurs when a connection
or pairing is made between a particular
stimulus and a particular response
What are associative learning processes?
Classical conditioning
Operant conditioning
What is nonassociative learning?
Nonassociative learning describes
behavior change as a result of
presentation of one stimulus repeatedly.
It also describes learning which has no
association with an end stimulus (such
as a reward or punishment).
What are nonassociative learning
processes?
Observational learning
Habituation
Sensitization
Associative Learning
Imprinting
Imprinting describes learning that
happens at a specific (usually early)
developmental stage. It is usually rapid
and is unrelated to the consequences of
the behavior being learned. During this
time, the animal or person imitates the
behavior of another stimulus.
What is imprinting?
35
What is an example of imprinting?
When birds follow the first thing they
see moving after they hatch. The critical
time period is the few moments after
birth and the association is made so
quickly that the first object that they
see suitably moving is what they will
follow.
Classical Conditioning
What is classical conditioning?
3
CS
CR
2
US
1
UR
Classical conditioning is a way of
pairing a stimulus and response. As
demonstrated by Pavlov, a novel
stimulus (a ringing bell) can be paired
with an unconditioned stimulus (food)
to elicit an unconditioned or natural
response (salivation).
Thus, if a bell (novel stimulus) is
rung every time food (unconditioned
stimulus) is presented to the dog,
it will be conditioned to associate
the bell with food and will learn to
salivate (natural response) at the
sound of the bell. This is the
conditioned response.
US: Unconditioned stimulus
CS: Conditioned stimulus
UR: Unconditioned response
CR: Conditioned response
1. Normally, unconditioned stimulus leads to
unconditioned response.
2. Conditioned stimulus paired with unconditioned
stimulus.
3. Now conditioned stimulus also leads to the response
—termed conditioned response.
Doctor’s office
3
Bell
Salivation
2
Food
1
Salivation
Pavlov’s example
Figure 5.1
Note: UR and CR are the
accurate terminology; the
response itself is still the same.
3
Nausea
2
Chemotherapy
1
Nausea
Medical example
Learning Theory 37
What is the term describing a similar
stimulus to the conditioned stimulus
eliciting the same response?
Stimulus generalization. The classic
example was “Little Albert” who was
conditioned to fear a white rat and was
subsequently afraid of other white
fuzzy things.
What is a medical example of classical
conditioning?
Phobias are believed to be results of
classical conditioning. For example,
Mary had a frightening experience on a
ship. She may generalize that fear so that
even the sight of a ship causes her
anxiety.
What is extinction?
It is the disappearance of the conditioned
response if the conditioned and
unconditioned stimuli are no longer
presented together.
Is it possible for the conditioned
response to be paired with the
conditioned stimulus after extinction
has taken place?
Yes, this is called spontaneous recovery.
What does learned helplessness mean?
The effect of repeatedly pairing an
adverse stimulus to the inability to
escape, leading to thoughts that no
efforts will be successful
What mood disorder may be explained
by the theory of learned helplessness?
It has been thought that this theory may
explain depression in humans. In this
theory, a person has tried repeatedly but
unsuccessfully to control external events.
The person then pairs any adverse event
to the inability to do anything about
them. The person then becomes hopeless,
depressed, and apathetic.
Operant Conditioning
What is operant conditioning?
It is the idea that a behavior is learned
because of the reward or punishment
associated with it.
What are the different consequences
in operant conditioning?
Positive reinforcement
Negative reinforcement
Punishment
Extinction
What are reinforcers?
Any event or stimulus that increases the
likelihood of the behavior occurring
again
What is positive reinforcement?
Presentation of a rewarding stimulus
after a certain behavior is performed.
For example, parents may reward their
children with ice cream (positive
reinforcer) when their rooms are clean,
thus increasing the likelihood that the
children will clean their rooms.
What is negative reinforcement?
Removal of an aversive stimulus after a
certain behavior is performed. For
example, parents may exempt the
children that clean their rooms from
having to take out the trash, thus
increasing the likelihood that the
children will clean their rooms.
What type of reinforcement increases
the likelihood of a behavior occurring
again?
Positive and negative reinforcement
What will decrease the likelihood
of a behavior occurring?
Punishment (note the contrast between
negative reinforcement and punishment)
What is shaping?
Shaping is learning that occurs when a
person is rewarded for a behavior
which is similar to a desired behavior.
Subsequently, only behavior which is
more and more similar to the particular
desired behavior is rewarded.
When is shaping used?
It is a progressive modification of
behavior which occurs by reinforcement
of behavior which is close to the desired
outcome.
What is the definition of punishment?
Presentation of an aversive stimulus to
reduce the likelihood of an unwanted
behavior occurring
What is the definition of extinction
in operant conditioning?
Extinction is the disappearance of a
certain behavior when the reinforcement
is no longer present.
What is an example of extinction?
A rat that is initially trained to press a
bar if rewarded with food will quickly
cease to press the bar if food is no
longer obtained by the behavior.
Learning Theory 39
What are the different schedules of
reinforcement?
There are five types of reinforcement
schedules:
1. Continuous: every time behavior is
performed
2. Fixed ratio: set number of times
3. Variable ratio: random number of
times
4. Fixed interval: set amount of time
5. Variable interval: random amount of
time
Which reinforcement shows the fastest
extinction when reinforcement is
taken away?
Continuous
What is variable ratio reinforcement?
Reinforcement is given at a variable
time interval after the behavior is
performed. This type of reinforcement
shows the slowest extinction when the
reinforcement is taken away. Slot
machines are an example of variable
ratio reinforcement.
classical and operant conditioning?
Classical conditioning refers to behaviors
learned by association of stimuli and
responses whereas operant conditioning
refers to behaviors learned by the
reward and reinforcement associated
with them.
NON-ASSOCIATIVE LEARNING
What is observational learning?
In observational learning, the observer’s
behaviors change based upon observing
the model’s behaviors. The consequences
of the model’s behaviors, whether they
are positive or negative, have an effect
on the observer’s behaviors.
If a person observes others and then
imitates their behavior, what is that
behavior called?
Modeling. Modeling is a type of
observational learning. Compared to
operant learning it is a more efficient
and faster type of learning. Modeling is
useful in acquiring new skills.
What four aspects are needed in order
for a person to be able to model?
1.
2.
3.
4.
Attention to the model
Retention of details
Motor reproduction
Motivation and opportunity
Where in medicine is modeling used?
The common saying, “see one, do one,
teach one,” is a description of modeling
in learning how to do medical
procedures.
Can modeling have a negative outcome?
Yes. Modeling may occur when a child
models the actions of a parent with a
particular phobia and hence also acquires
the same phobia or perpetuation of
abuse by an abused person.
Can modeling have a positive outcome?
Yes. Modeling may involve other
types of learning, eg, seeing a role
model/mentor’s behavior achieve
a positive result would then act as
a positive reinforcer (which would
be an example of operant
conditioning).
What is habituation?
Habituation occurs when stimulus
presentation results in decreased
responsiveness.
What is an example of habituation?
You may notice the hum of the air
conditioner when it first comes on,
but due to habituation, your
awareness of that continual hum
will decrease and you can focus
on your studies.
How is habituation used in medicine?
Habituation is used to overcome
phobias. Some of the specific techniques
using habituation are flooding and
systemic desensitization.
How do you describe flooding?
It is excessive presentation of the
stimulus to achieve quick habituation
by preventing escape and forcing
a reduction in the associated
behavior.
What is an example of flooding?
One could force an individual with
an obsession about germs to touch
a toilet.
How do you describe systematic
desensitization?
In systematic desensitization, the
patient is gradually exposed to
anxiety-producing situations while
simultaneously teaching relaxation or
anxiety-reducing techniques.
Learning Theory 41
What is sensitization?
Sensitization occurs when stimulus
presentation results in increased
responsiveness and/or generalization of
response to other stimuli.
What is an example of sensitization?
Joe is alone in a dark house when he
hears a sudden loud noise. He suddenly
becomes more aware of every little
sound in the house.
Intelligence Tests
Which term is used to describe the
ability to learn, understand, or to deal
with new or trying situations?
Intelligence
Which term did Binet use to describe
the average intellectual age of people
with a specific chronological age?
Mental age
Which scale is used to determine a
person’s IQ?
Stanford-Binet scale
How is the IQ calculated?
(Mental age/chronological age) × 100
If a person has an IQ of 100, what does
that indicate?
Mental and chronological age are
equivalent.
If a person has an IQ <70, what does
that indicate?
Mental retardation
What happens to the IQ throughout the
course of a person’s life?
Remains generally stable
Which IQ range indicates that a person
has an average intelligence?
90 to 109
Which IQ range indicates borderline
to low average intelligence?
71 to 89
50 to 70
Which IQ range indicates moderate
mental retardation?
35 to 55
Which IQ range indicates severe
mental retardation?
20 to 40
Which IQ range indicates profound
mental retardation?
<20
CLINICAL VIGNETTES
An 8-year-old girl with acute myelogenous leukemia (AML) gets weekly
chemotherapy treatments. The chemotherapy makes her very nauseated, but her
mother makes up for it by taking her to an ice cream shop by the hospital. Her
favorite flavor is maple nut. After the first month of treatment, she will no longer
eat ice cream as it causes intense nasusea.
What are the unconditioned stimulus (US), unconditioned response (UR),
conditioned stimulus (CS), and conditioned response (CR) in this situation?
US: chemotherapy; UR: nausea; CS: ice cream; CR: nausea
The patient also refuses to eat pancakes with maple syrup. What is this
phenomenon?
Ice cream has been paired with chemotherapy here. The patient has also generalized
the maple ice cream to the syrup, eliciting the same nausea.
After the patient’s AML is in remission and her treatment is over, her parents
slowly reintroduce her to eating progressively larger amounts of ice cream while
listening to her favorite calming music. What is this process called?
Her parents are later using the process of systematic desensitization to unpair the
CS with the US.
A rat is being conditioned to press a lever in its cage, but not the button next to it.
Name the operant conditioning consequence or phenomenon represented by each
statement:
The rat is given a piece of cheese when it gets close to the lever. Subsequent
pieces of cheese are given as it gets closer and closer, finally resulting in a big
piece when it finally presses it.
Shaping
The rat receives a piece of cheese every time the lever is pressed.
Positive reinforcement
The rat cage floor is electrified, but pressing the lever deactivates it.
Negative reinforcement (note the behavior will increase)
The rat presses the button and a loud and terrifying noise is emitted.
Punishment (note the behavior will decrease)
The rat continues to press the lever, but nothing happens. He eventually stops
pressing the lever.
Extinction
The floor of the cage is electrified by the cruel scientist, and no amount of lever
or button pressing will turn it off. The rat gives up.
Learned helplessness
CHAPTER 6
Sleep Science and
Disorders
NORMAL SLEEP
REM (rapid eye movement) and NREM
(nonrapid eye movement). NREM is
divided into four stages: 1, 2, 3, and 4.
What are the normal stages of sleep?
Awake
Sleep stage
REM
Stage 1
Stage 2
Stage 3
Stage 4
Time asleep
Figure 6.1
Slow wave sleep occurs during stages 3
and 4 of NREM sleep. It is also known
as delta sleep and is the deepest portion
of sleep. Electroencephalogram (EEG)
shows delta waves, which are the
lowest frequency waves.
Delta waves = Deep sleep
What is slow wave sleep?
43
What waveforms are seen in
REM sleep?
Beta waves. These are of highest
frequency.
Where else are beta waves seen?
They are found over the frontal lobes in
a person who is awake with their eyes
open. These are associated with a
person who is alert and actively
concentrating. In a person who is awake
with their eyes closed, alpha waves are
seen typically over the occipital and
posterior parietal lobes.
What waveforms are associated with
Stages 1 and 2 of NREM?
Stage 1 (light sleep) is associated with
theta waves and Stage 2 (deeper sleep)
is associated with sleep spindles and
K-complexes.
On average, how much time does a
normal adult spend in each stage
of sleep?
REM: 25%
NREM: 75%
1. Stage 1: 5%
2. Stage 2: 45%
3. Stage 3: 25%
4. Stage 4: 25%
What is REM latency?
REM latency is the length of time after
falling asleep before REM sleep occurs.
What is the length of REM latency
in an adult?
REM latency in an adult is approximately
90 minutes. The REM sleep cycle then
repeats itself approximately every
90 minutes thereafter.
Besides rapid eye movements, what
other physiologic changes occur in
REM sleep?
Pulse, respiration, blood pressure, and
brain oxygen use increase. There is
penile/clitoral erection, dreaming, and
decreased skeletal muscle tone.
How is this different from the
physiologic changes in NREM sleep?
In NREM, blood pressure, pulse, and
respiration are slow. There may also be
intermittent limb movements.
Tip: This makes sense—if your blood
pressure (BP) and pulse are up and
your genitals are aroused, NREM sleep
wouldn’t be very restful!
Which neurotransmitter usually
initiates sleep?
Serotonin. It is released from the dorsal
raphe nucleus and is a derivative of
tryptophan. It increases total sleep time
and slow wave activity.
Tip: Turkey is high in tryptophan—this
is why you get sleepy after a big
Thanksgiving dinner.
Sleep Science and Disorders 45
Which neurotransmitters are involved
in REM sleep?
Acetylcholine (ACh) from the basal
forebrain and norepinephrine (NE) from
the locus ceruleus. ACh increases REM
sleep and NE decreases it.
How does REM change with age?
Time spent in REM decreases with age.
What effect does dopamine have on the
sleep cycle?
Dopamine increases wakefulness. Thus,
antipsychotics, which block dopamine,
can result in increased sedation.
Stimulants, which increase both NE and
dopamine, promote wakefulness.
ABNORMAL SLEEP
Approximately how many adults
experience sleep disorders every year?
About one in three
What is the most common type
of sleep disorder?
Insomnia, which includes problems
initiating and maintaining sleep.
What is a primary sleep disorder?
Sleep disturbances that arise from
endogenous sources, not from substance
use, medical problems, or other
psychiatric problems. Primary sleep
disorders are divided into two major
categories:
1. Parasomnias
2. Dyssomnias
dyssomnias and parasomnias?
Dyssomnias are due to dysfunctional
sleep regulation characterized by
problems initiating or maintaining
sleep, or excessive daytime sleepiness.
Parasomnias involve abnormal behaviors
or physiologic events during sleep,
rather than abnormal functioning of the
usual mechanisms of sleep. These include
sleep terror disorder, sleepwalking
disorder, and nightmare disorder.
Name the five major dyssomnias
1.
2.
3.
4.
5.
Primary insomnia
Primary hypersomnia
Narcolepsy
Breathing-related sleep disorder
Circadian rhythm sleep disorder
How long must you have problems
with insomnia before primary
insomnia can be diagnosed?
At least 1 month
What interventions other than
medications can be useful
in insomnia?
Set a regular bedtime, abstain from
caffeine and alcohol, use the bed only
for sleep and sex, and avoid daytime
naps and strenuous exercise or large
meals just before bedtime. Collectively,
this is referred to as sleep hygiene.
What is the subtype of recurrent
primary hypersomnia associated with
obesity, impulsivity, hyperphagia,
hypersexuality, and disorganized
thought called?
Kleine-Levin syndrome
Other than daytime sleepiness and
“sleep attacks,” what symptoms are
classically associated with narcolepsy?
Cataplexy: sudden loss of muscle
tone associated with strong emotions
Hypnagogic and hypnopompic
hallucinations: REM intrusions that
occur during the transition period
between sleep and wakefulness
(Hypnagogic symptoms occur when
going to sleep and hypnopompic occur
while waking up.)
Sleep paralysis: inability to move just
before going to sleep or awakening
Which class of drugs is normally used
to treat narcolepsy?
Stimulants, eg, Ritalin
Why are people with breathing-related
sleeping disorder chronically sleepy
during the day?
During the night they frequently stop
breathing and then are awoken by
hypoxia. These frequent arousals
prevent the patients from getting deep,
restful sleep.
What is the most common cause
of breathing-related sleep disorder
and how is it treated?
Obstructive sleep apnea (OSA)
Treatment: continuous positive airway
pressure (CPAP) and possibly removal
of tonsils and adenoids (ideally weight
loss would be primary intervention
in the obese.)
In a patient with excessive fatigue,
what might the patients’ bed partner
tell you about their sleep that might
lead you to suspect obstructive sleep
apnea (OSA)?
Loud snoring and periods of time
where the patient appears to stop
breathing
What are the complications from
untreated OSA?
Hypertension, pulmonary hypertension,
and increased all-cause mortality,
cardiovascular disease, and
cerebrovascular disease
Sleep Science and Disorders 47
In a person with sleep problems related
to OSA, why might you avoid
benzodiazepines?
You risk further compromising the
patient’s ventilation by respiratory
depression.
What are the three most common causes
of a circadian rhythm sleep disorder?
1. Delayed sleep phase—“night owls,”
more common in adolescents and
tends to improve with age
2. Jet lag—typically resolves over
several days
3. Shift work—eg, working the
night shift
During which phase of sleep would
you expect nightmares to occur in?
REM
What are the similarities between sleep
terrors and sleepwalking?
Both are more common in children and
may involve semicomplex to complex
motor behaviors. Patients tend to be
amnestic for both and in adulthood they
are equally prevalent in men and
women (1% prevalence of sleep terrors
and 2% prevalence of sleepwalking).
Both occur in slow wave sleep.
How could you clinically differentiate
sleep terror from sleepwalking?
Sleep terror has strong component of
autonomic arousal and fear, often
beginning with a terrified scream, and a
lesser element of semipurposeful motor
behaviors. Sleepwalking has minimal
autonomic arousal/fear and motor
behaviors are usually more complex.
What is the treatment of sleep terrors
and sleepwalking?
Children will usually grow out of them.
Benzodiazepines can be helpful for
adults, as can scheduled awakenings
and environmental control.
OTHER SLEEP CHANGES
What polysomnogram (PSG) findings
are characteristic of major depression?
Reduced slow wave sleep (less delta
waves), frequent nighttime awakenings,
increased sleep latency (time until
falling asleep), short REM latency
(REM cycle starts sooner than normal
90 minutes onset), and early morning
waking.
Tip: Low serotonin is associated with
depression; therefore you would expect
reduced total sleep and slow wave sleep.
A common feature of Alzheimer is
reduced ACh. Given this, what PSG
changes are seen in an individual
with Alzheimer?
Decreased slow wave and REM sleep
CLINICAL VIGNETTES
A 51-year-old obese man presents to your clinic because of fatigue. He states that
he is sleepy all the time and will often fall asleep at inopportune times—at
meetings, during lunch, and even behind the wheel. He says that he goes to bed at
10 PM and wakes up at 6 AM every morning. He denies any substance use. What
should he be screened for?
Sleep apnea. Obese patients are at increased risk for this and can often present as
daytime sleepiness as sleep is not restorative. He should be evaluated with a sleep
study. First-line treatment is CPAP.
A 32-year-old woman is being evaluated because of strange “spells”. She often
seems to “pass out” when she is startled or when she laughs quite hard. What
sleep disorder is she most likely suffering from?
Narcolepsy. The described phenomenon is cataplexy.
An 83-year-old woman presents to your office because she feels as though she is
spending less time getting a restful sleep at night. She has heard from her friends
that there are changes in sleep that occur with aging. What stages of sleep tend to
decrease with age?
Both REM and later stage deep sleep (3 and 4) decrease in the elderly, as well as a
decrease in overall quantity of sleep.
CHAPTER 7
Sexuality
SEXUAL DEVELOPMENT
Which sex is the default pattern for
sexual development?
Female
Gonad differentiation is dependent
upon the presence of which
chromosome?
Y chromosome
Which gene present on the
Y chromosome influences gonad
development?
SRY Gene, which makes testisdetermining factor
Which duct system present in male
embryos helps form genitalia?
Wolffian duct system
Which duct system in female embryos
help form female genitalia?
Mullerian duct system
Which organ secretes hormones that
direct the differentiation of male
internal and external genitalia?
Testes
How does exposure to different levels
of hormones during prenatal life
influence humans?
It causes gender differences in certain
areas of the brain.
What term describe an individual’s
sense of being male or female?
Gender identity
At which age(s) does gender awareness
become evident?
2 or 3 years of age
What term describes the expression
of gender identity in society?
Gender role
What term describes the conflict people
experience when they feel as if they
were born as the wrong gender?
Gender identity disorder
49
According to the DSM-IV-TR
is homosexuality a dysfunction
of sexual expression?
No, it is a normal variant.
What is the difference between sex
and gender?
Sex refers to the genetics of the
individual (XX or XY), gender is
what a person identifies as
(male or female).
What type of behavior in childhood
may be predictive of later homosexual
orientation?
Cross-gender behavior → stronger
correlation in males
Which hormones have been shown
to influence sexual orientation?
Prenatal hormones → low levels of
androgens in males and high levels of
androgens in females
Which evidence has been reported,
which indicates that genetics plays
a role in homosexuality?
Higher concordance rate observed in
monozygotic twins than in dizygotic
twins
On which chromosome have genetic
markers been found in homosexuals?
X chromosome
SEXUAL DEVELOPMENT AND PHYSIOLOGIC ABNORMALITIES
Which disorder is characterized by
cells that are not responsive to
androgens and testicles that may
appear as inguinal or labial masses?
Androgen insensitivity which is also
called testicular feminization
What is the genotype of a person with
androgen insensitivity?
XY
What is the phenotype of a person with
androgen insensitivity?
Female
Which disorder is characterized by an
adrenal gland that is unable to produce
the proper amount of cortisol which
leads to a significantly increased
androgen secretion?
Congenital adrenal hyperplasia
congenital adrenal hyperplasia?
XX
congenital adrenal hyperplasia?
Female with genitalia that are masculine
Sexuality 51
What is the sexual orientation of 33%
of patients with congenital adrenal
hyperplasia?
Homosexual
Which disorder is characterized by a
short stature, webbed neck, and
streak ovaries?
Turner syndrome
Turner syndrome?
XO
Turner syndrome?
Female
HORMONES AND THEIR INFLUENCE ON BEHAVIOR
Which hormone may be decreased by
an increase in stress?
Testosterone
Which three hormones commonly used
in medical treatment of conditions such
as prostate cancer decrease androgen
production and in turn reduces sexual
interest and behavior?
1. Androgen antagonists
2. Estrogens
3. Progesterone
Which hormone is believed to play the
most important role in sex drive in
both genders?
Testosterone
Which hormone may decrease sexual
behavior and interest in women?
Progesterone → this hormone is in many
oral contraceptives.
SEXUAL RESPONSE CYCLE
What are the four stages in the sexual
response cycle developed by Masters
and Johnson?
1.
2.
3.
4.
Excitement
Plateau
Orgasm
Resolution
What is the primary characteristic of
the excitement stage in men?
Penile erection
What are characteristics of the
excitement stage in women?
Clitoral erection
Vaginal lubrication
Labial swelling
Uterus raises in pelvic cavity → tenting
effect
What characteristics of the excitement
stage are common to men and women?
Nipple erection
Elevation of blood pressure, pulse, and
respiration
What are characteristics of the recovery
stage in men?
Refractory period in which stimulation
is not possible
What happens to the refractory period
of men as they age?
Increases
What is the primary characteristic
of the recovery stage in women?
Minimal or no refractory period
What are characteristics of the refractory
period that are common to both men
and women?
Physiological systems return to their
prestimulated states (eg, cardiovascular,
respiratory)
Muscle relaxation
SEXUAL DYSFUNCTION
Which term(s) describe problems in
stages of the sexual response cycle?
Sexual dysfunction
pain associated with sexual intercourse?
Dyspareunia
Which gender is most likely to
experience dyspareunia?
Females
inability to maintain vaginal lubrication
throughout the duration of a sexual act?
Female sexual arousal disorder → occurs
in approximately 20% of women
decreased interest in sexual activity?
Hypoactive sexual desire
problems with maintaining erections?
Male erectile disorder also called
impotence
Which disorder is characterized by an
inability to achieve an orgasm?
Orgasmic disorder → this disorder can
be lifelong or acquired.
anxiety and ejaculation before
a man desires?
Premature ejaculation
Which stage of the sexual response
cycle is affected by premature
ejaculation?
Plateau phase → absent or reduced
Sexuality 53
avoidance or aversion to sexual
activity?
Sexual aversion disorder
painful muscular spasms in the outer
one-third of the vagina making pelvic
examination or sexual intercourse
difficult?
Vaginismus
Which behavioral treatment stimulates
a person’s senses during sexual
activity to reduce the pressure one
experiences when trying to achieve
an erection or orgasm?
Sensate-focus exercise
What is the primary goal of the squeeze
technique?
To treat premature ejaculation
Which segment of the nervous system
is used to initiate an erection?
Parasympathetic
Which segment of the nervous system
is used to initiate an ejaculation?
Sympathetic
What is a mnemonic to remember this?
Point and Shoot
Which behavioral technique(s) are used
to reduce anxiety associated with
sexual performance?
Hypnosis
Which drug is used to treat erectile
dysfunction by blocking the
phosphodiester-5 (PDE-5) enzyme
thereby inhibiting cyclic guanosine
monophosphate (cGMP)?
Sildenafil citrate (Viagra)
What is the role of cGMP in sexual
stimulation of the penis?
It is a vasodilator which allows an
erection to persist.
Which drug is used to increase the
availability of dopamine in the brain
in patients with erectile disorder
and female arousal disorder?
Apomorphine (Uprima)
What injection method is used to treat
erectile dysfunction?
Intracorporeal injection of vasodilators
Which vasodilators are commonly
injected in intracorporeal injection?
Papaverine
Phentolamine
Relaxation techniques
Systematic desensitization
PARAPHILIAS
What term describes the use of
unusual objects of sexual desire or
unusual sexual activities?
Paraphilia
Which paraphilia is most common and
is characterized by a person who
achieves sexual gratification from
children <14 years of age?
Pedophilia → perpetrator must be at
least 16 years of age and at least 5 years
older than victim
Which paraphilia is characterized by
exposing genitals to strangers?
Exhibitionism
achieving sexual gratification from
inanimate objects?
Fetishism
recurrent urges to rub against or
touch a noncompliant person in a
sexual manner?
Frotteurism
a sexual gratification with corpses?
Necrophilia
causing humiliation and physical
suffering to achieve sexual
gratification?
Sexual sadism
being the recipient of humiliation and
physical suffering to achieve
sexual gratification?
Sexual masochism
achieving sexual gratification by
wearing women’s clothing?
Transvestic fetishism
watching others engage in sexual
activity and undress?
Voyeurism
INFLUENCE OF MEDICAL CONDITIONS ON SEXUALITY
What effect does a myocardial
infarction have on sexual activity?
Decreased libido
Erectile dysfunction
Sexuality 55
Which postmyocardial infarction
patients can resume sexual activity?
Patients who can tolerate increases in
heart rate from 110 to 130 bpm
Which problem is common in
diabetic men?
What are the two main causes of
erectile dysfunction in diabetics?
1. Diabetic neuropathy
2. Vascular changes
What is the primary treatment for
erectile dysfunction in diabetics?
Metabolic control monitored by
hemoglobin A1c level
What effect does spinal cord
dysfunction have on sexual
functioning in men?
Decreased fertility
What effect does pregnancy have on
sexual functioning?
Decreased sex drive → most common.
Increased sex drive and pelvic
vasocongestion may occur.
During what time period prior to
pregnancy should a woman
cease sexual activity?
4 weeks before expected delivery
Orgasmic dysfunction
Reduced testosterone levels
Retrograde ejaculation into the bladder
EFFECTS OF DRUGS AND NEUROTRANSMITTERS ON SEXUALITY
Decreased availability of which
neurotransmitter(s) causes a decrease
in erection?
Dopamine (eg, chlorpromazine,
haloperidol)
Norepinephrine β (eg, propranolol,
metoprolol)
Increased availability of which
neurotransmitter(s) causes a
decrease in ejaculation and orgasm?
Serotonin (eg, fluoxetine, sertraline,
trazodone)
Increased availability of which
neurotransmitter(s) causes an increase
in erection?
Dopamine (eg, levodopa)
Norepinephrine in α2 in the periphery
(eg, yohimbine)
Which drug(s) of abuse causes
increased libido with acute use?
Alcohol
Marijuana
Which drug(s) of abuse causes
increased libido?
Amphetamines
Cocaine
Which drug(s) of abuse causes erectile
dysfunction due to increased estrogen
availability as a result of liver damage?
Alcohol → with chronic use
Which drugs(s) of abuse causes reduced Marijuana → with chronic use
testosterone levels in men and lowered
pituitary gonadotropin levels in women?
Which drug(s) of abuse causes reduced
libido and inhibited ejaculation?
Heroin
Methadone
CLINICAL VIGNETTES
A news program reports on a man who is causing problems in the local subway.
As the doors open he rubs up against unsuspecting victims and then runs away.
What is the name for this disorder?
Frotteurism
A 32-year-old male who is happily married does not become sexually aroused
unless his wife wears a specific black negligee. He has always had an obsession
with objects to give him sexual gratification. Which sexual paraphilia does this
patient have?
Fetishism
A 25-year-old female experiences intense painful vaginal spasms whenever she
goes to get a pelvic examination and engages in sexual intercourse. She has begun
psychological counseling to treat her condition. Which type of sexual dysfunction
does she suffer from?
Vaginismus
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CHAPTER 8
Abuse and Aggression
CHILD AND ELDER ABUSE AND NEGLECT
What are the primary types of child
and elder abuse?
Physical
Sexual
Emotional
What are the primary traits of a
child abuser?
Young parents
Substance abuse
Social isolation
Stress in the household
History of victimization by spouse or
caretaker
What traits in a child make them more
likely to be abused?
Child that has already been abused
Low birth weight, premature infant
Learning disability or language disorder
Adopted child or stepchildren
Hyperactive
What is the most common age range
of children that are abused?
<3 years of age
What are key signs of child neglect?
Lack of proper nutrition
Poor personal hygiene
What are common sites of bruises on
a victim of child abuse?
Lower back and buttocks → areas not
commonly injured during normal
activities
What type of marks might one see on a
victim of child abuse?
Linear bruises and marks, often at
multiple stages of healing
What are characteristics of the fractures
on a victim of child abuse?
Fractures at different stages of healing
Spiral fractures → due to twisting limbs
57
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What are the two primary burn types
on victims of child abuse?
1. Cigarette burns
2. Immersion burns on legs, feet, or
buttocks → child is immersed in
scalding water
What are other warning signs for child
abuse/non-accidental trauma?
History inconsistent with level of child’s
motor development, bite marks,
and any facial trauma or bruising
What is the classic physical finding
of shaken baby syndrome?
Retinal hemorrhage
What type of cultural healing practices
may leave markings that are important
to distinguish from child abuse?
Cupping (use of heated cups to suction
out illness)
Coining or Spooning (rubbed on body
leaving linear marks)
What are the primary traits of an
elder abuser?
Social isolation
Substance abuse
Close relationship to the abused (eg,
spouse, offspring) → person with whom
the elder lives and receives financial
support from
What are the primary traits of an elder
who experiences elder abuse?
Some decline of mental functioning
(eg, dementia)
Economical or physical dependence on
others
Not likely to report injuries as abuse →
will state that they injured themselves
What are key signs of elder neglect?
Lack of proper nutrition
Poor personal hygiene
Lack of proper medication or health
aids (eg, prescription drugs, dentures,
cane)
What are characteristics of the bruises
seen on a victim of elder abuse?
Bilateral arm bruises from being
grabbed
What is the annual incidence of
child sexual abuse cases in the
United States?
More than 250,000 cases
Has the likelihood of reporting child
sexual abuse increased or decreased
when compared with the past?
Increased
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Abuse and Aggression 59
Which gender is more likely to report
sexual abuse during their lifetime?
Girls → 25% will report vs 12% boys
Which gender is most likely to
be the perpetrator of child
sexual abuse?
Males
Will the perpetrator of a child sexual
abuse more likely be a stranger or
someone the child knows?
Relative or acquaintance (eg, father,
uncle, friend of the family, etc)
What are some traits of child sexual
abusers?
Interpersonal relationship problems
(eg, marriage problems)
History of substance abuse
May have a history of pedophilia
What is the primary age range of
children who are victims of
sexual abuse?
9 to 12 years of age
What emotions is the victim of a child
sexual abuse likely to experience?
Guilt
Shame
Fear of abuser’s response if he or she
notified someone else of his or her
experience
What are the common physical signs
of child sexual abuse?
Sexually transmitted infection
(eg, human papillomavirus [HPV],
herpes, chlamydia)
Recurrent urinary tract infection
(UTI)
Genital or anal injury
Note: Physical signs may be absent in a
victim of child sexual abuse.
What are common psychological signs
of child sexual abuse?
Inappropriate knowledge about sexual
events out of proportion for a given age
range
Excessive initiation of sexual activity
with peers
What are common physical signs of
elder sexual abuse?
Genital bruising
Vaginal bleeding in women
What types of emotional abuse do
children experience?
Lack of caregiver attention and love
Physical neglect
Caregiver rejection
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What types of emotional abuse do
elders experience?
Neglect of needed care (eg, medical,
hygiene, etc)
Economic exploitation
How many cases of child and elder
abuse are reported annually?
1,000,000 cases each
What is the physician’s responsibility
if they suspects child or elder abuse?
By law, the physician must report the
case to appropriate social service
agency.
DOMESTIC PARTNER ABUSE
What are primary findings seen
in women who are victims of
domestic violence?
Broken bones
Bruises
Blackened eyes
What factor can greatly increase the
likelihood of an abused person being
killed by their abuser?
If the abused person leaves the abuser.
What is the primary gender of the
perpetrator of domestic violence?
Male
What are the characteristics of the
abuser in a domestic violence situation?
Substance abuse
Angry
Threatens to kill the abused
Apologetic after abuse has occurred
What are the characteristics of the
May be pregnant
abused in a domestic violence situation? May not report abuse to police
May not leave the abuser
Blame themselves for the abuse
Emotional and financial dependence on
the abuser
What characteristic is common to both
the abused and the abuser in a
domestic violence situation?
Low self-esteem
What is the role of the physician, in
terms of reporting, if notified of
domestic violence abuse?
The physician does not have mandatory
reporting since the abused is generally a
competent adult. The physician can
provide emotional support and
encourage the abused to report the
violence.
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SEXUAL VIOLENCE
What is the definition of sexual assault? A person commits a sexual assault when
he or she uses force or the threat of force
to touch another person sexually in a
way that person does not want or when
that person cannot give consent because
of physical or mental inability.
Note: Sexual assault is the legal term for
rape.
What are examples of force that can be
used to commit a sexual assault?
Manipulation
Coercion
Physical force
Use of weapons
Use of isolation
Use of substances—alcohol and other
drugs
What is the definition of consent?
Giving permission by giving a “yes”
response
What term describes oral and anal
penetration?
Sodomy
What is the primary age group
of a rapist?
<25 years of age
What is the racial background of a
perpetrator of sexual assault?
Perpetrator will generally be the same
race as the victim.
Which substance is most frequently
used in cases of sexual assault?
Alcohol
What percentage of rapes are
acquaintance rapes (ie, the victim
knows the perpetrator)?
Approximately 85% of rapes
What percentage of rapes are reported
to the police?
Approximately 10%—rape is the most
underreported violent crime in the
United States.
What is the age group most likely to
experience a sexual assault?
16 to 24 years of age
What is the most common place
for a sexual assault to occur?
In the victim’s home
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Which disorder do/may sexual assault
survivors experience?
Posttraumatic stress disorder
Which type of treatment is the best
option for survivors of sexual assault?
Group therapy
Is it possible for spouses to be
convicted of committing a sexual
assault against each other?
Yes
What terms describes consensual sex
that is considered rape?
Statutory rape
With which group(s) of people would
consensual sex be considered
statutory rape?
Laws vary by state—usually consensual
age is either 16 or 18, but some states
have age difference limits (eg, not over
3 years difference if under 18 years old)
Profoundly disabled persons
What is the role of the physician
if they suspect a sexual assault?
Laws vary by state—depending on age
of the victim, this may fall under
mandatory reporting for child or elder
abuse; in adult cases it is the victims’
choice to report.
AGGRESSION
What has happened since the 1990s
to the incidence of homicide in the
United States?
Decreased
Which weapon is most commonly used
in a homicide?
Guns
What are risk factors for being victims
of homicide?
Male sex
Alcohol and drug users
<65 years of age
Which racial group is most likely to be
affected by a homicide?
Young African American males
How does violence on television or
video games influence aggression
in children?
Direct correlation with increased
aggression in children
Which gender is most likely to be most
aggressive?
Males
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Why are many body builders and some
professional athletes likely to show
increased aggression?
Use of androgenic or anabolic steroids
increases aggression.
Use of which drugs is associated with
increased aggression?
Alcohol
Amphetamines
Cocaine
Phencyclidine
Marijuana (high doses)
Which neurotransmitter(s) is associated
with increased aggression?
Dopamine
Norepinephrine
Which neurotransmitter(s) is associated
with decreased aggression?
Serotonin
γ-Aminobutyric acid (GABA)
What type of injury is most likely to be
associated with violence?
Head injury
CLINICAL VIGNETTES
A family who has newly immigrated to the United States comes to your family
practice to establish care. The son in the family has been suffering from a chronic
cough and the parents are worried. Upon examination you find well-demarcated,
circular, purpuric lesions on his back. They don’t look accidental. What should you
do?
Ask the family about their cultural practices. This could represent a cultural
healing technique such as “cupping” used to heal the boy’s cough. It is important
to distinguish this from child abuse.
A 21-year-old female college student decides to go on a date with her boyfriend of
2 years. She consumes a large volume of alcohol while out. When they return to
her dorm room, the boyfriend tries to coerce her into having sex with him. She
passes out without agreeing. Since they’ve had had sex before, he cites their longterm relationship as proof of consent. Would this incident be considered sexual
assault?
Yes—a long-term relationship (or even marriage) does not substitute or replace
consent. Even if the woman agreed to intercourse, an intoxicated person is unable
to give consent and the act would still be considered sexual assault.
CHAPTER 9
Suicide
SUICIDE
What is important to keep in mind
when approaching the topic of suicide
on the United States Medical Licensing
Exam (USMLE) Step 1?
There is only a limited amount of
information that you will be asked
regarding suicide. Always think safety
first when given a question regarding a
psychiatric disorder. Statistics,
demographics, and risk factors, and
comorbid medical disorders will
probably be the focus of the exam
content. Many of the questions will
come in the form of a case scenario
written to ascertain if you know the
correlation between suicide and
comorbid mental health diagnoses such
as depression, bipolar disorder, and/or
chemical dependence.
Where does suicide rank as a cause of
death in the United States?
As of 2002, suicide ranks 10th as the
leading cause of death.
What are risk factors for committing
suicide?
White male, >65 years old
Gun in the house or easy access to
firearms
Comorbid depression, substance abuse,
and/or other psychiatric illness
Recent loss or stressor
Serious medical illness
Feelings of hopelessness and
impulsivity
Men are four times more likely to
complete suicide, though women are
more likely to attempt suicide.
Who commits suicide more frequently,
men or women?
65
What accounts for this difference?
Men tend to use more lethal means
(firearms, hanging) and women less
lethal (pill overdose).
What age group has the highest
suicide rate?
• The elderly (65 and older). Despite
What has happened to the suicide rate
in child and adolescent groups over
the last 40 years?
It has risen significantly over the last
40 years with a mortality rate of 12%,
though declined since 1990.
What is the most significant risk factor
of suicide?
A previous attempt.
You should become extremely cautious
if the attempt is recent (eg, within
3 months) and if the nature of the
attempt is well-thought out and
deliberate.
What are other risk factors for suicide
(in decreasing order)?
1.
2.
3.
4.
How is suicide most commonly
committed or attempted?
Firearms are the number one method
for completed suicide, regardless of
gender.
Other common methods include
jumping, hanging, overdose,
and drowning.
Is there racial disparity among those
who commit suicide?
Yes, whites commit suicide more than
any other group. However, the suicide
rate among young black males is slowly
increasing.
What are the most common comorbid
medical disorders associated
with suicide?
Major Depressive Disorder
Anxiety Disorders
Posttraumatic Stress Disorder (PTSD)
Schizophrenia
Bipolar Disorder
Personality Disorders
Substance Abuse
being only 14% of the population,
they comprise about 18% to 25%
of the total suicide percentage.
• The elderly suicide rate is 40 per
100,000 persons in comparison to the
national US rate of 12 per 100,000.
Persons >45 years
Alcohol dependence
History of violence or aggression
Male gender
Suicide 67
At what stage, in treated major
depression, is suicide attempted?
For adults, suicide is most attempted
after pharmacologic treatment has
begun. The patient has more energy and
is better able to function but low mood
and hopelessness may persist.
Are there special concerns about
children and adolescents treated
for depression?
There is FDA black box
warning for all antidepressants that
use in children and adults younger than
25 may increase suicidal thoughts and
behaviors. When starting such a
medication in this population, frequent
and close monitoring for suicidality is
important.
When do you assess for suicidality?
At every follow-up assess for:
• Ideation
• Plan (possibility and practicality)
• Intent to carry out the plan
• Access to firearms
What is the difference between active
and passive suicidal ideation?
Passive: Patient would like to be dead
(eg, “I wish I were dead!”)
Active: Patient actually wants to harm
him/herself (eg, “I am going to shoot
myself with a gun.”)
Can suicide attempts be predicted?
There is no reliable means to predict
suicide attempts with a reasonable
degree of specificity and sensitivity.
How can suicidal ideation be managed?
If suicide risk is imminent, the patient
must be detained and the appropriate
mental health care sought.
If suicide risk is not imminent,
assessment and defusing risks is
important (eg, removing firearms from
house, involving family members
if possible).
Antidepressant medication should be
started and the patient should be
followed closely and seen frequently.
What antidepressant would be the first
choice in a suicidal patient?
Aggressive SSRI (selective serotonin
reuptake inhibitor) therapy is the best
choice—avoid monoamine oxidase
(MAO) inhibitors and tricyclics in a
patient with active suicidal ideation as
they can be lethal in an overdose.
What are protective factors from
suicide?
• Marriage: Single persons that are
divorced, have never married, or
widowed have higher suicide rates
than married persons. Living alone
and limited social and family support
are also risk factors.
• Employment: Persons who are
unemployed have higher suicide
rates. However, among employed US
citizens, those working in professional
roles (doctors, lawyers, and in law
enforcement) have higher suicide
rates than nonprofessional persons.
• No family history of a completed
suicide or an attempted suicide is
protective because once suicide
occurs, it seemingly decreases the
social “taboo” of suicide in the family.
CLINICAL VIGNETTES
A patient in your outpatient clinic presents with suicidal ideation, but no current
intent to harm himself. You would like to decrease the probability of him
committing suicide and so prescribe him a high-dose SSRI. Will this eliminate his
suicide risk?
Though aggressive treatment is indicated and untreated depression carries a high
risk of suicide, treatment with SSRI alone will not necessarily eliminate risk of
suicide. Screening for associated risk factors such as access to firearms and other
lethal means is also indicated.
CHAPTER 10
Genetic Basis
of Behavior
GENETIC STUDIES
What type of study uses a family tree
to show the occurrence of traits and
diseases throughout generations?
Pedigree study
What type of study compares the
frequency of disease in a proband
(affected individual) with its frequency
in the general population?
Family risk study
What type of study compares
monozygotic and dizygotic twins
to determine the effects of genetic
factors from environmental factors
of disease?
Adoption study
This term describes if both twins have
a given trait.
Concordance
What type of twins is more likely
to have a higher likelihood of having
a disease that is genetic in origin?
Monozygotic twins
PSYCHIATRIC DISORDERS GENETICS
What is the prevalence of schizophrenia
in the general population?
1%
In which gender is schizophrenia more
likely?
Equal in males and females
Which persons have a higher likelihood
of developing schizophrenia?
Persons with a close genetic relationship
69
Genetic markers on which
chromosome(s) are associated with
schizophrenia?
1, 6, 8, and 13
Does schizophrenia have a familial
component?
Yes—the closer a relative you are, the
more likely you are to develop
schizophrenia; but concordance in twins
is not 100%.
What is the likelihood of developing
schizophrenia if you are a first-degree
relative of an affected individual?
10%
What is the likelihood that a child
will develop schizophrenia if both
parents have the disorder?
40%
What is the likelihood that the
monozygotic twin of a patient with
schizophrenia will develop the
disorder?
50%
any mood disorder if you are a firstdegree relative of a person with bipolar
disorder?
25%
any mood disorder if someone is a child
with both parents who have bipolar
disorder?
60%
bipolar disorder if you are the
monozygotic twin of a person with
the disorder?
80% to 90%
Is the genetic component stronger for
schizophrenia or bipolar disorder?
Bipolar disorder
In which gender is the lifetime
prevalence of a major depressive
disorder higher?
Females
What is the percentage of males who
will develop a major depressive
disorder in their lifetime?
10%
What is the percentage of females
who will develop a major depressive
disorder in their lifetime?
15% to 20%
Genetic Basis of Behavior 71
Do personality disorders have a higher
concordance in monozygotic twins
demonstrating that they have a genetic
component?
Yes
If a person has antisocial personality
disorder, what psychiatric condition(s)
will be prevalent in relatives?
Alcoholism
Attention-deficit hyperactivity disorder
(ADHD)
If a person has avoidant personality
Anxiety disorder
If a person has borderline personality
Major depressive disorder
Substance abuse
If a person has histrionic personality
Somatization disorder
If a person has schizotypal personality
Schizophrenia
NEUROPSYCHIATRIC DISORDER GENETICS
In which disease is there a diminution
of cognitive functioning and a
likelihood of genetic influence?
Alzheimer disease
Which chromosome has three copies in
Down syndrome, and is also implicated
in some cases of Alzheimer disease?
Chromosome 21
Note: Down syndrome patients often
develop early-onset Alzheimer.
What other chromosome(s) have been
identified to be associated with
Alzheimer disease?
Chromosomes 1 and 14
Which gene has been implicated in
many cases of Alzheimer disease?
The gene encoding Apolipoprotein
E4 (Apo E4)
In which chromosome is the Apo E4
gene located?
Chromosome 19
What disease has an abnormal gene
on the short end of chromosome 4?
Huntington disease
What is the most common genetic cause
of mental retardation?
Down syndrome
What is the second most common
genetic cause of mental retardation?
Fragile X syndrome
What disorder, characterized by verbal
and motor tics, has a genetic
component?
Tourette disorder
ALCOHOLISM GENETICS
What is the prevalence of alcoholism
in children of alcoholics compared
to the general population?
Four times more prevalent
What is the concordance rate of
alcoholism in monozygotic twins?
60%
What is the concordance rate of
alcoholism in dizygotic twins?
30%
Which gender offspring of alcoholics
is more likely to become alcoholics
themselves?
Male offspring
In which age group is the genetic
influence of alcoholism strongest
in males?
<20 years of age
CLINICAL VIGNETTES
A 17-year-old woman comes to your office worried that she might become
schizophrenic. She hasn’t had any symptoms, but she says that some of her family
members are schizophrenic. What would be important historical information to
assess her risk?
How closely related she is to those family members with schizophrenia. The more
genetically similar to them she is, the higher her risk is.
A 41-year-old Down syndrome patient has had a gradual deterioration in cognitive
functioning. Lately, she has been unable to remember her home address, and her
daughter has noticed that she has difficulty remembering names of people she has
known throughout the duration of her life. Her primary care physician diagnoses
her with Alzheimer disease. Which chromosome has been implicated in Alzheimer
disease in Down syndrome patients?
Chromosome 21
Genetic Basis of Behavior 73
A 19-year-old male is brought to the emergency room by his college roommate for
delusions, hallucinations, and disorganized speech that has occurred for the last
7 months. The roommate is concerned that the patient may have schizophrenia. The
patient’s father was diagnosed with schizophrenia at age 22. Not taking into account
these new symptoms, what is the lifetime likelihood of this patient developing
schizophrenia?
The patient is a first-degree relative of an affected individual—he therefore has a
10% chance of developing schizophrenia.
CHAPTER 11
Neurochemistry in
Behavioral Sciences
NEUROANATOMY
What are the two divisions of the
nervous system?
1. Central nervous system (CNS)
2. Peripheral nervous system (PNS)
What are the two main components
of the CNS?
1. Brain
2. Spinal cord
Which brain structures connect
the cerebral hemispheres?
Corpus callosum
Commissures: anterior, posterior,
hippocampal, and habenular
Which hemisphere is usually the
dominant hemisphere?
Left hemisphere
What is the primary role of the left
hemisphere?
It governs our ability to express
ourselves in language.
Which hemisphere is usually the
nondominant hemisphere?
Right hemisphere
What is the primary role of the right
hemisphere?
It governs perceptual functions and the
analysis of space, geometrical shapes,
and forms.
What are the components of the
peripheral nervous system?
Nerve fibers outside the CNS including
cranial nerves, spinal nerves, and
peripheral ganglia
How many cranial nerves are there?
12 cranial nerves
How many spinal nerves are there?
31 pairs of spinal nerves: 8 cervical,
12 thoracic, 5 lumbar, 5 sacral, and
1 coccygeal
75
In which direction does the PNS carry
motor and sensory information
to the CNS?
Motor information: away from the CNS
Sensory information: to the CNS
What are the components of the
autonomic nervous system?
Sensory neurons and motor neurons
that run between the CNS (especially
the hypothalamus and medulla oblongata)
and various internal organs.
BRAIN LESIONS
What will be the neuropsychiatric
consequences of a frontal lobe lesion?
Deficits in concentration, judgment,
motivation, and orientation
Disinhibition
Personality and emotional changes
consequences of a parietal lobe lesion?
Right parietal lobe → (contralateral
neglect) result in neglecting part of the
body or space
Left parietal lobe → verbal deficits
consequences of a temporal lobe lesion?
Hallucinations
Memory deficits
Personality changes
consequences of a hippocampus lesion?
Bilateral damage to hippocampus leads
to massive anterograde and some
retrograde amnesia.
Unilateral damage of hippocampus
leads to memory storage and retrieval
problems.
consequences of an amygdala lesion?
Kluver-Bucy syndrome → uninhibited
behavior, hyperorality, hypersexuality
consequences of a reticular system
lesion?
Sleep-wake cycle changes
consequences of a basal ganglia lesion?
Tremor or other involuntary movements
as seen in Parkinson or Huntington
diseases
consequences of a hypothalamus
lesion of the ventromedial nucleus?
Decreased satiety → leads to obesity
Neurochemistry in Behavioral Sciences 77
consequences of a hypothalamus lesion
of the lateral nucleus?
Decreased hunger → leads to weight loss
of the anterior hypothalamus?
Disturbances of parasympathetic
activity
Disturbances of body cooling
of the posterior hypothalamus?
Disturbances of heat conservation
of the septate nucleus?
Change in sexual urges and emotions
of the suprachiasmatic lesion?
Disturbances of circadian rhythm
NEUROTRANSMITTERS
What are the four main steps involved
in neurotransmitter release?
1. Presynaptic neuron stimulation.
2. Neurotransmitter release.
3. Neurotransmitter moves across
synaptic cleft.
4. Neurotransmitter acts on
postsynaptic neuron receptors.
What are the two different types of
neurotransmitters?
1. Excitatory: increase neuron firing
2. Inhibitory: decrease neuron firing
What are the two main excitatory and
inhibitory neurotransmitters
in the CNS?
1. Excitatory: glutamate
2. Inhibitory: γ-aminobutyric acid
(GABA)
Which factors contribute to the
magnitude of reaction
neurotransmitters
have on neurons?
1. Affinity of receptors
2. Number of receptors
What are the three major classes of
neurotransmitters?
1. Amino acids
2. Biogenic amines
3. Peptides
How are neurotransmitters removed
from the synaptic cleft?
Reuptake by the presynaptic neuron
Degradation by enzymes (eg, monoamine
oxidase)
Why is this important in pharmacology?
These are common targets for
psychotropic drug actions (eg, SSRIs,
MAO inhibitors)
Table 11.1 Neurotransmitter Alterations in Psychiatric Conditions
Alzheimer
Disease
Anxiety
Acetylcholine
Depression
Mania Schizophrenia
↓
↓
Dopamine
GABA
↓
Norepinephrine
↑
↓
Serotonin
↓
↓
↑
↑
↑
AMINES
Which amines are included in the
biogenic amines, which are also called
the monoamines?
Catecholamines
Ethylamines
Indolamines
Quaternary amines
What is the monoamine theory
of depression?
It proposes that there is an underlying
neuroanatomical basis for depression
due to deficiencies of central
noradrenergic and/or serotonergic
systems.
Why are metabolites of monoamines
measured in psychiatric studies?
They may be present in higher levels
than the primary monoamines.
What type of biogenic amine
is dopamine?
Catecholamine
In which psychiatric condition(s) is an
altered level of dopamine evident?
Mood disorders
How is dopamine synthesized?
By the conversion of tyrosine to
dopamine by tyrosine hydroxylase
Parkinson disease
Schizophrenia
tyrosine hydroxylase
tyrosine ⎯⎯⎯⎯⎯⎯⎯⎯⎯→ dopamine
What is the main metabolite
of dopamine?
Homovanillic acid (HVA)
In which psychiatric condition(s) can
there be an increased concentration
of HVA?
Psychotic disorders
Schizophrenia
there be a decreased concentration
of HVA?
Alcoholism
What type of biogenic amine is
norepinephrine?
Catecholamine
What behavioral factors does
norepinephrine alter?
Anxiety
Arousal
Depression
Parkinson disease
Learning
Memory
Mood
How is norepinephrine synthesized?
Dopamine is converted to
norepinephrine by β-hydroxylase.
β-hydroxylase
dopamine ⎯⎯⎯⎯⎯⎯→ norepinephrine
Where are most noradrenergic neurons
located in the brain?
Locus ceruleus
What are the metabolites of
norepinephrine?
3-Methoxy-4-hydroxyphenylglycol
(MHPG)
Vanillylmandelic acid (VMA)
there be a decreased concentration
of MHPG?
Severe depression
In which medical condition is
there an increased concentration
of VMA?
Pheochromocytoma → a tumor of the
adrenal medulla
is serotonin?
Indolamine
Note: Another name for serotonin is
5-hydroxytryptamine (5-HT).
What behavioral factors does
serotonin alter?
Impulse control
Mood
Sleep
Sexuality
If serotonin levels are increased, which
behavioral factors will be improved?
Mood
Sleep
If serotonin levels are increased, which
behavioral factors will be impaired?
Sexual functioning
If serotonin levels are decreased, which
behavioral factors will be impaired?
Impulse control
Sleep
Note: Patient is likely to experience
depression.
How is serotonin synthesized?
Tryptophan is converted to serotonin by
tryptophan hydroxylase and an amino
acid decarboxylase.
Where are most serotoninergic cell
bodies located in the brain?
Dorsal raphe nucleus
Which pharmacologic agents are used
to alter the level of serotonin in
the brain?
Antidepressants—eg, selective serotonin
reuptake inhibitors (SSRIs)
What is the primary metabolite of
serotonin?
5-Hydroxyindoleacetic acid (5-HIAA)
In which psychiatric condition(s) is
there a decreased concentration
of 5-HIAA?
Alcoholism
Bulimia
Impulsive behavior
Pyromania: uncontrollable desire to set
things on fire
Severe depression
Tourette syndrome
Violent behavior
is histamine?
Ethylamine
Which pharmacologic agents block
the histamine receptor?
Antipsychotic drugs
Tricyclic antidepressants (TCAs)
What are side effects of the histamine
receptor blockade?
Increased appetite → contributing to
weight gain and obesity
Sedation
is acetylcholine (ACh)?
Quaternary amine
Where is acetylcholine normally
found in the body?
Neuromuscular junctions
Which psychiatric conditions are
associated with a decrease in
cholinergic neurons?
Alzheimer disease
Down syndrome
Movement disorders
How is acetylcholine synthesized?
Acetyl coenzyme A (CoA) and choline
are converted to acetylcholine by
choline acetyltransferase in cholinergic
neurons
How is acetylcholine degraded?
Acetylcholine esterase (AChE) degrades
acetylcholine into acetate and choline.
Which pharmacologic agents have been
shown to reduce the degradation
of acetylcholine?
Donepezil
Tacrine
Note: These agents can slow the
progression of diseases such as
Alzheimer disease.
What are the three primary amino acid
neurotransmitters?
1. GABA
2. Glutamate
3. Glycine
Which amino acid neurotransmitter(s)
are excitatory?
Glutamate
Which amino acid neurotransmitters(s)
are inhibitory?
GABA—primary inhibitory
neurotransmitter
Glycine
Which pharmacologic agents alter
duration and frequency of GABA?
Barbiturates: alter duration of GABA
channel opening
Benzodiazepines: alter frequency of
GABA channel opening
Which neurotransmitter regulates
glutamate activity?
Glycine
Which pathologic conditions may
glutamate play a role in?
Cell death mechanisms
Epilepsy
Neurodegenerative diseases
Psychotic disorders (eg, schizophrenia)
NEUROPEPTIDES
What are the two endogenous opioids?
1. Endorphins
2. Enkephalins
What behavioral factors do endogenous
opioids alter?
Anxiety
Mood
Pain
Seizure activity
Temperature regulation
Which factor does endogenous
opioids alter in research studies?
Placebo effects → endogenous opioids
are thought to play a major role in the
placebo effects seen in research studies.
Which neuropeptide(s) has been
implicated in aggression and pain?
Substance P
Which neuropeptides have been
implicated in Alzheimer disease?
Somatostatin
Vasoactive intestinal peptide (VIP)
implicated in mood disorders?
Oxytocin
Somatostatin
Substance P
Vasopressin
VIP
implicated in schizophrenia?
Cholecystokinin (CCK)
Neurotensin
CLINICAL VIGNETTES
A man in your neighborhood has had a recent accident that caused brain damage.
You notice his personality is much different now and he seems to have trouble
with higher thought processes. He now also uses profanity more often. What part
of his brain was most likely damaged?
The frontal lobe
SECTION II
Psychiatric
Disorders and
Treatment
CHAPTER 12
Psychotic Disorders
INTRODUCTION
What is the most used book of criteria
for the diagnosis of psychiatric
disorders?
DSM-IV-TR
What are the five axes used in the
DSM-IV-TR?
1. Axis I: Major psychiatric disorder
2. Axis II: Personality disorders and
mental retardation
3. Axis III: Medical conditions
4. Axis IV: Environmental factors
5. Axis V: Global assessment of
functioning (0-100)
What is an important criterion
of most DSM-IV-TR disorders?
The symptoms cause significant
social or functional impairment.
This distinguishes a disorder from
a normal variant.
What strategy will help when learning
the different types of disorders?
Try to focus on differences between
similar disorders—they may have to
do with duration, severity, or subtle
features present or absent in a disorder.
DISORDERS
What is psychosis?
Significant impairment in reality
testing (ability to distinguish real
from imaginary)
What are the clinical hallmarks
of psychosis?
Delusions: fixed false beliefs, despite
evidence to the contrary
Hallucinations—usually auditory
Disorganized speech (thought disorder)
Grossly disorganized or catatonic
(stupor and bizarre posturing) behavior
85
a hallucination and an illusion?
An illusion is the misperception of
an actual sensory stimulus (eg, seeing
a pool of water on the road ahead
during a hot summer day),
whereas hallucinations are
perceptions in the absence of
an external stimulus.
Name the six major primary psychotic
disorders.
1. Brief psychotic disorder (<1 month
of symptoms)
2. Schizophreniform disorder (1 to
6 months of symptoms)
3. Schizophrenia (>6 months of
symptoms)
4. Schizoaffective disorder
5. Delusional disorder
6. Shared psychotic disorder
Other than primary psychotic disorders,
what other types of psychiatric illness
often manifest psychotic symptoms?
• Mood disorders: Major depression or
•
•
•
•
•
manic episodes may include psychotic
symptoms, but only during a mood
disturbance.
Substance use: Acute intoxication
(especially with cocaine, lysergic acid
diethylamide [LSD], phencyclidine
[PCP], and amphetamines) or
withdrawal (especially alcohol).
Anytime a patient has tactile
hallucinations, you should think
about drugs.
Personality disorders: May be
associated with brief (not sustained)
periods of psychosis.
Cognitive disorders: Both delirium
and dementia demonstrate psychosis.
Often delirium will have visual
hallucinations in addition to clouded
sensorium.
Psychosis due to a general medical
conditions such as Vitamin B12
deficiency, Multiple Sclerosis (MS),
Systemic Lupus Erythematosus (SLE),
uremia, etc.
Narcolepsy: May have
hypnagogic and hypnopompic
hallucinations.
Psychotic Disorders 87
Schizophrenia
Which of the primary psychotic
disorders is the most common?
Schizophrenia. The incidence
in the adult population is
around 1%.
What are the DSM-IV-TR criteria
for Schizophrenia?
Two or more characteristic symptoms:
• Delusions
• Hallucinations
• Disorganized speech
• Grossly disorganized behavior
• Negative symptoms
And social/occupational dysfunction
And disturbance lasting 6+ months
(including any prodrome or
residual)
And not due to Schizoaffective disorder
or General Medical Condition or
substance use
What are negative symptoms?
Negative symptoms (think deficits) include
affective flattening, alienation (social
withdrawal), alogia (poverty of
speech), and avolition (lack of
motivation).
What are considered the positive
symptoms of schizophrenia?
Usually this refers to the hallucinations,
delusions, bizarre behavior, and thought
disorder.
What is a “first-rank” symptom?
A particularly bizarre delusion, or
hallucinations consisting of either a
voice running commentary on the
patient’s activities or two voices
conversing. A first-rank symptom
may satisfy both symptom
requirements of the DSM-IV-TR
criteria above.
How does the criterion of
disorganized speech, (also referred
to as thought disorder) manifest
in schizophrenia?
Abnormalities in thought processes and
thought formation
Give at least two examples of abnormal
thought formation.
• Word salad: Words and phrases are
•
•
•
•
•
combined together in incoherent
manner.
Neologisms: Creation of new words.
Echolalia: Repeating the same word
over and over (almost like a mental
stutter).
Loose associations: Illogical shifting
between unrelated or obliquely
related topics.
Thought blocking.
Circumstantial and tangential
thought: Circumstantial thought
eventually gets to the point;
tangential never does.
Z
Y
X
X
A
B
Normal
A
Y
W
B
Circumstantial
A
B
Tangential
What is meant by the prodromal and
residual phases of schizophrenia?
These are periods of time before and
after active psychotic periods,
respectively. These periods are
generally characterized by attenuated
symptoms of the active phase, eg, social
withdrawal, peculiar behavior, or odd
affect.
During these periods a person would
seem strange but would not necessarily
meet criteria for psychotic.
How long must you have symptoms for
before schizophrenia can be diagnosed?
At least 6 months including prodromal
and residual phases, but they must have
at least 1 month of active characteristic
symptoms (above), as well as decline in
function.
How does schizophreniform disorder
differ from schizophrenia?
The duration is <6 months, but is at
least 1 month. It also does not require a
decline in function.
What would you call psychosis lasting
<1 month?
Brief Psychotic Disorder (which lasts
over 24 hours, but <1 month).
Does gender affect the development
of schizophrenia?
There is no difference in the prevalence
of schizophrenia between men and
women; however, the age of onset is
affected. Men tend to develop it
between 15 and 25 years of age and
women between 25 and 35 years of age.
What other epidemiological factors
are correlated with increased risk
of schizophrenia?
Having a first degree relative with
schizophrenia increases a patients’ risk
of schizophrenia tenfold. Being born in
the cold winter months or in an area of
high population density have also been
associated with increased risk (though
less so).
What is downward drift?
This is the tendency of schizophrenics
to be of lower socioeconomic status.
It is generally thought that this is due
to inability to function well in society,
causing a “drift” into lower
socioeconomic classes.
What is the dopamine hypothesis?
This is the classic understanding of
schizophrenia, which attributes the
symptoms of schizophrenia to
hyperactivity of the dopaminergic
system. Many other theories have
been postulated, however, especially
involvement of Glutamate.
Are there any structural brain changes
associated with schizophrenia?
Increase in size in the lateral and
third ventricles, generalized atrophy
of the cortex, and frontal lobe
abnormalities are often associated
with schizophrenia.
What are the five major subtypes
of schizophrenia?
1.
2.
3.
4.
5.
Which form tends to have the best
social functioning?
Paranoid. They also tend to be slightly
older at onset, and have prominent
hallucinations and delusions, with a
lesser component of disorganization.
Which form is the least common?
Catatonic. Prior to the development
of antipsychotics, this form was
more common.
Paranoid
Residual
Catatonic
Disorganized
Undifferentiated
What is catalepsy and waxy flexibility?
Catalepsy is the ability of a catatonic
patient to hold a seemingly uncomfortable
position for extended periods of time.
Waxy flexibility is the slight resistance
given to moving the limbs, after which
the patient will often hold the new
position given.
What is the most predictive of overall
prognosis in schizophrenia?
Level of premorbid function
Overall, schizophrenia is associated
with repeated psychotic episodes, and
a chronic downhill course. What
features are associated with a somewhat
better prognosis?
Abrupt onset, female gender, presence
of mood symptoms, and old age at onset
Are patients with schizophrenia at risk
of suicide?
Yes! Over half of schizophrenics
will attempt suicide at some point in
their lives, and 10% will die from it.
What is the primary treatment for
schizophrenia?
Antipsychotics.
What is the difference between typical
and atypical antipsychotics?
Typical antipsychotics are older and
tend to work by antagonizing dopamine.
Comparatively they have higher rates
of extrapyramidal symptoms (EPS) and
tardive dyskinesia (TD).
Atypical antipsychotics are newer, have
complex mechanisms, have less EPS
and TD, are more expensive, and have
more metabolic side effects.
What is EPS?
This includes tremor, rigidity, akathisia
(inner restlessness), and acute dystonias
(muscle spasm).
How do you treat EPS?
Anticholinergics (eg, diphenhydramine
and benztropine)
What is tardive dyskinesia?
Abnormal movements of the face,
trunk, extremities, and mouth that
may happen after prolonged exposure
to antipsychotic medications.
How do you treat tardive dyskinesia?
Early identification and removal
of the offending antipsychotic drug.
With early recognition, remission rates
are reasonably high. Benzodiazepines
can be used for mild persistent cases.
What are some differences between
EPS and TD to remember?
EPS can develop quite quickly, whereas
TD tends to come on after prolonged
exposure to medicines—months to years.
TD is not helped by anticholinergics
and may become worse. TD is also
more often permanent.
What is a potentially fatal side effect
of antipsychotic treatment?
Neuroleptic malignant syndrome
(NMS). This is an idiosyncratic
reaction that is more common in
young men, usually after recently
starting a new antipsychotic.
Mortality is nearly 20%.
How does NMS present?
Fever, muscle rigidity, altered mental
status, and autonomic instability
What is the first thing you should do
if a patient presents to the ER
with NMS?
Stop the antipsychotic! Then care is
primarily supportive.
Other Psychotic Disorders
What is the DSM-IV-TR criteria
for Schizoaffective Disorder?
Must meet criteria for either a major
depressive episode, a manic episode,
or a mixed episode at the same time
as meeting characteristic symptoms of
schizophrenia. The schizophrenic
symptoms must persist in the
absence of mood symptoms.
What are the two types of
schizoaffective disorder?
1. Bipolar
2. Depressed
How could you differentiate
between a mood disorder with
psychotic symptoms (eg, major
depressive disorder [MDD] with
psychosis or Bipolar Mania) from
schizoaffective disorder?
A person that has a mood disorder with
psychotic symptoms will not have
psychosis without a mood disturbance.
Schizoaffective patients have psychosis
at some point even when they are not
experiencing an affective disturbance.
Tip: Look at the names! For example, in
schizoaffective disorder, the emphasis is
on the schizo. The primary problem is a
psychotic disorder that sometimes has
a mood component, whereas in MDD
with psychosis, the emphasis is on
MDD. The main problem is a mood
disorder that when severe, may have
a component of psychosis.
What is a delusional disorder?
Patients with delusional disorder tend
to have an isolated, fixed, nonbizarre
delusion (eg, the Internal Revenue
Service [IRS] is after them, or their partner
is cheating). Even if the delusion is
unfounded, it is plausible. They are not
disorganized in thoughts or affect, and
patients do not meet criteria for
schizophrenia.
What are some types of delusions
that may occur in this disorder?
1. Erotomanic: Someone is in love with
patient.
2. Somatic.
3. Grandiose.
4. Jealous: Wife/husband is cheating.
5. Persecutory: Patient is being
mistreated.
What is a shared psychotic disorder?
A rare disorder where the patient
believes the delusions of another person
with a primary psychotic disorder.
CLINICAL VIGNETTES
A 27-year-old male presents to your clinic with a 4-year history of hallucinations
and delusions for which he has been intermittently managed with antipsychotics.
He is currently untreated. He also complains of 4 months of depressed mood,
weight loss, insomnia, fatigue, and loss of interest in activities. He denies using
any illicit substances or having any other medical conditions. What is the most
likely diagnosis?
Schizoaffective Disorder. Note that there have been psychotic symptoms without
affective symptoms present, but now also meets criteria for a depressive episode.
A 76-year-old man presents with 1 year of worsening depressive symptoms. He has
trouble falling asleep, feels worthless, cannot concentrate, and has thoughts of
death. Over 3 years ago his wife passed away from cancer. For 6 months now he
has adamantly stated that the cancer was his fault and that he was the one that
killed his wife, despite all evidence to the contrary. He also often hears her voice
scolding him when no one is around. What is the most likely diagnosis?
Depression with Psychotic Features. Note the mood-congruent delusion in the
setting of depression and psychotic symptoms that only appear during affective
episode. Also remember schizophrenia rarely presents in this advanced age.
CHAPTER 13
Mood Disorders
Five or more of following symptoms
present for at least 2 weeks (one of
which must be either depressed mood
or anhedonia):
Depressed mood
Anhedonia
Fatigue
What are the DSM-IV-TR criteria for a
major depressive episode?
Increase or decrease in sleep
Increase or decrease in appetite or weight
Decrease in ability to concentrate
Feelings of worthlessness or guilt
Psychomotor retardation
Recurrent thoughts of death or suicidal
ideation
What is anhedonia?
Loss of pleasure in all or almost all
activities
What is SIG E CAPS?
It is a mnemonic for depression:
Sleep disturbances (mainly insomnia)
Loss of Interest
Excessive Guilt
Loss of Energy
Loss of Concentration
Loss of Appetite
Psychomotor retardation or agitation
Suicidal ideation (or recurrent thoughts
of death)
5% to 12% for men and 10% to 20%
for women, with a 2:1 female to
male ratio
What is the prevalence of major
depressive disorder (MDD)?
93
Does MDD appear at a certain age?
The mean age of onset is 40.
What are the medical conditions that
can cause or mimic a depressive
episode?
Thyroid dysfunction (particularly
hypothyroidism)
Malignancy
Stroke (Post-stroke depression)
Neurodegenerative disorders
Mononucleosis
Acquired immunodeficiency syndrome
(AIDS)
Syphilis
Parkinson disease
Stroke
Multiple sclerosis
Lupus
Nutritional deficiency
Menopause
What medications can cause depressed
mood?
Accutane (isotretinoin)
Reserpine
Beta-blockers
Steroids (eg, prednisone)
Methyldopa
Interferon (used to treat viral hepatitis)
Oral Contraceptive Pills
What is double depression?
This term is used when a patient meets
criteria for both MDD and dysthymic
disorder.
What is “postpartum onset” depression
(aka postpartum depression, PPD)?
A major depressive episode happening
within 4 weeks of delivery (some believe
within 12 months of delivery is still
PPD)
What is the diagnostic criteria for
dysthymic disorder?
Depressed mood for a least 2 years,
plus two more symptoms of major
depression, but not meeting criteria
for MDD
How can you differentiate dysthymic
disorder from MDD?
Dysthymic disorder must last longer,
but is less severe.
How do you treat depression
pharmacologically?
The first-line treatment option is the
selective serotonin reuptake inhibitors
(SSRIs) (see Table 13.1).
Mood Disorders 95
Table 13.1 SSRIs and Their Unique Properties
Generic Name
Brand
Name
Side Effects
Other
Citalopram
Celexa
Standard
(Sexual side
effects, nausea,
vomiting,
headache, anxiety,
insomnia)
Fewest medication
interactions
Escitalopram
Lexapro
Standard
Isomer of
citalopram, very
similar
Fluoxetine
Prozac
Standard
Long half-life,
drug-drug
interactions
Paroxetine
Paxil
Standard, plus
has anticholinergic
effects that can
cause weight gain,
constipation,
and sedation
Short half-life, can
cause withdrawal
symptoms (except
CR form), drugdrug interactions
Sertraline
Zoloft
Most GI side
effects
Very few drug-drug
interactions
Abbreviations: GI, gatrointestinal.
Are there any other antidepressants
also considered as first-line treatment
options?
Yes, there are other antidepressants
with different mechanism of action
(see Table 13.2).
Table 13.2 Other Antidepressants Indicated for the Treatment of Depression
Generic
Name
Brand
Name
Mechanism
of Action
Side
Effects
Bupropion
Wellbutrin
Zyban (for
smoking
cessation)
Unknown, likely
via dopamine
and
norepinephrine
Mirtazapine
Remeron
Presynaptic alpha-2- Highly
adrenergic
sedating,
antagonist (↑
↑appetite,
norepinephrine
↑weight
and serotonin)
also potent
antagonist of
5-HT2 and
5-HT3
Agranulocytosis
in 0.1%
Also used to
↓ nausea
Trazodone
Desyrel
Weakly inhibits
serotonin
reuptake
Highly
sedating,
orthostatic
hypotension
Uncommon
but can
cause
priapism
(painful
erection)
and
arrhythmias
Used as a
sleeping aid
Headache,
dry mouth,
blurred
vision,
somnolence,
and
orthostatic
hypotension
FDA black-box
warning due
to risk of liver
failure
Postsynaptically
antagonizes
5-HT2
Nefazodone Serzone
Similar to
trazodone
Seizures,
insomnia,
headache,
nausea,
vomiting,
constipation,
and tremor
Other
Contraindicated
in patients with
seizures,
bulimia, and
anorexia
Used to treat
sexual side
effects caused
by SSRIs
Mood Disorders 97
Table 13.2 Other Antidepressants Indicated for the Treatment of Depression (Continued )
Generic
Name
Brand
Name
Mechanism
of Action
Side
Effects
Other
Venlafaxine
Effexor
Serotonin and
norepinephrine
reuptake
inhibitor, also
inhibitor of
dopamine
reuptake at
high doses
Nausea,
dizziness,
sexual
dysfunction,
headache,
and dry
mouth
Can increase
blood pressure
Duloxetine
Cymbalta
Similar to
venlafaxine
Nausea, dry
Also indicated
mouth,
for neuropathic
constipation, pain
diarrhea,
dizziness,
and
insomnia
What are tricyclic antidepressants
(TCAs)?
Older antidepressants (also known as
heterocyclics) are currently considered
a second-line treatment option.
Why are tricyclics a second-line
treatment option?
Greater side effects and lethality in
overdose
What are the side effects of tricyclic
antidepressants?
Anticholinergic effects: dry mouth,
blurred vision, constipation, and
confusion
Alpha-blocking effects: sedation also
caused by antihistaminic effects,
orthostatic hypotension, and cardiac
arrhythmias
May lower the seizure threshold
Are contraindicated in glaucoma
Must be used with caution in urinary
retention
What are the most commonly used
tricyclics?
Amitriptyline, desipramine, imipramine,
and nortriptyline
Are there any other medications to
treat depression?
Yes, the monoamine oxidase inhibitors
(MAOIs), considered third-line option.
MAOIs are rarely used any more.
Why are MAOIs a third-line option?
The main reason for not using them
is due to the drug-drug interactions
and diet restrictions. If these are not
strictly followed, they may cause
serotonin syndrome and
hypertensive crisis.
What is serotonin syndrome?
A clinical entity that consists of
hyperthermia, muscle rigidity, and
altered mental status. This syndrome
is seen when MAOIs are combined
with SSRIs (mostly), Demerol,
pseudoephedrine, and other
medications that can increase
serotonin and norepinephrine.
When does a hypertensive crisis occur
in the context of MAOI use?
Hypertensive crisis originates when
patients who are on MAOIs ingest food
rich in tyramine, like wine and cheese,
or take medications such as
sympathomimetics, bronchodilators,
DOPA, etc.
When are MAO inhibitors particularly
efficacious?
Atypical depression (those with
increased appetite and sleep) and
treatment-resistant depression
Are there any other ways to treat
depression?
Yes, by using psychotherapy or
electroconvulsive therapy in severe
depression
What type of psychotherapy is used
to treat depression?
Cognitive-behavioral therapy, which
attempts to recognize negative thoughts
or behaviors and then tries to change
them
Psychodynamic psychotherapy, which
focuses on self-understanding and
inner conflicts
Interpersonal therapy, which examines
the patient’s problems in relation to
their symptoms and how to deal with
those problems
Mood Disorders 99
What is electroconvulsive therapy
(ECT)?
It is the induction of a generalized
seizure by applying electric currents
to the brain.
When is ECT used?
It is mainly indicated for patients with
refractory or psychotic depression, but
it can also be used for the treatment of
mania.
What are the main side effects
of ECT?
Short-term memory loss
What are the DSM-IV-TR diagnostic
criteria for a Manic Episode?
A 1-week period of elevated,
expansive, or irritable mood (or less
if hospitalized) with at least three
of the following (four if mood
irritable):
Grandiosity or inflated self-esteem
Decreased need for sleep
More talkative
Flight of ideas/racing thoughts
Distractibility
Increased goal-directed activity
Involvement in pleasurable and risky
activities
hypomania and mania?
Hypomanic episodes last 4 days or
more and do not require hospitalization
or involve psychotic features. In
general, hypomania is less severe
than mania.
What is a mixed episode?
A 1-week or longer period in which
criteria for both manic and major
depressive episodes are met.
How do you diagnose Bipolar I
Disorder?
The patient has one or more manic or
mixed episodes. Usually there is also a
depressive episode, but this is not
required for the diagnosis.
Table 13.3 Mood Stabilizers for Chronic Treatment of Bipolar Disorder and Unique
Properties (Either I or II)
Generic Name
Brand Name
Side Effects
Other
Carbamazepine
Tegretol,
Carbatrol,
Equetro
Sedation, GI,
reversible mild
leukopenia,
reversible mild
increase in LFTs,
tremor,
hyponatremia
Induces
metabolism of
itself and other
medications,
decreasing its
own level during
therapy
Associated with
aplastic anemia and
agranulocytosis
Must monitor
levels
Lamotrigine
Lamictal
Rash may occur
in 10% of
individuals, may
rarely
progress to
Stevens-Johnson
syndrome (rare)
has been
reported
Good for
depressed state,
rapid cycling,
and mixed states
Start low and go
slow to avoid rash
No level
monitoring
required
Lithium
Eskalith
Tremor,
nephrogenic
diabetes
insipidus,
hypothyroidism,
GI symptoms,
teratogen,
weight gain
Narrow
therapeutic
index, can cause
toxicity with ↑
sweating,
NSAIDs, or
thiazides
diuretics
Must monitor
levels
Valproic acid
Depakote
Rare fatal
hepatotoxicity,
agranulocytosis
Teratogen: folic
acid antagonist
→neural tube
defects
Benign elevation
of transaminases,
GI side effects,
sedation, tremor,
alopecia,
weight gain
Inhibits
metabolism of
other
medications
(↑ their level)
Must check LFTs
and monitor
level
Abbreviation: LFTs, Liver function tests; NSAIDs, nonsteroidal anti-inflammatory drugs.
100
Mood Disorders 101
How do you diagnose Bipolar II
Disorder?
The patient has one or more major
depressive episodes, plus one or more
hypomanic episodes (but never any
manic episodes).
Are there any drugs that induce mania?
Yes, steroids and appetite suppressants
are the main culprits. Cocaine (crack)
and amphetamines may also induce it.
Previously undiagnosed bipolar
patients who have only been treated
for a major depression may have their
manic episodes precipitated by
treatment with antidepressants.
What is cyclothymic disorder?
Cyclothymic patients meet criteria for
dysthymic disorder and experience
hypomanic episodes.
What is the prevalence of bipolar
disorder?
Bipolar I has a lifetime prevalence of
0.5% to 1% and a male to female ratio
of 1:1. While, bipolar II has a lifetime
prevalence of 0.5% and is more common
in women than in men.
CLINICAL VIGNETTES
You are the third-year medical student on the psychiatry consult service. You and
your resident are called to the ER for a patient who was recently admitted to the
inpatient psychiatry service for depression and suicidal ideation. While in the
hospital, he complained of having trouble sleeping and was given a medication to
help both his depression and sleep problems. The patient also received a
prescription for this medication when he was discharged. He now presents to the
ER with a 3-hour history of a painful erection. What drug was the patient most
likely given?
Trazodone
A patient you have been treating for depression with SSRIs comes to you for a
checkup. When you ask how he is he says “The last 3 days have been fantastic!”
and launches into a very long and tangential story about what he has been doing.
The patient has been very productive at work, though that might have to do more
with the small amount of sleep that he has been getting, but he claims that he is
far too strong to need sleep. What is your new diagnosis?
Bipolar, type II. This meets criteria for a hypomanic episode, but because of the
lack of psychosis or need for hospitalization it is not yet mania. He is also very
functional during this time.
A 29-year-old woman comes to the ER worried about a new rash. She has never
had a rash like this before. She has no risk factors that you can identify and hasn’t
been hiking in any areas with poison oak. She says she has just started therapy
with an anticonvulsant drug to treat her bipolar disorder. She has no allergies that
she knows of.
What drug is she likely taking?
Lamotrigine, a maintenance therapy for bipolar disorder. She is experiencing a
drug rash, which is common with this drug.
What should you do at this point?
Stop the medication
What is the serious complication you would like to avoid?
Stevens-Johnson Syndrome. Though rash is common, rarely some patients will
progress to Stevens-Johnson Syndrome.
CHAPTER 14
Anxiety Disorders
What are the most prevalent psychiatric
disorders?
Anxiety disorders
What are the major types of anxiety
disorders?
Generalized anxiety disorder (GAD)
Panic disorder
Social phobia
Specific phobia
Obsessive-compulsive disorder
Agoraphobia
Posttraumatic stress disorder (PTSD)
Acute stress disorder (ASD)
What is the most prominent feature
of all anxiety disorders?
The presence of a sense of impending
doom or threat
What differentiates anxiety disorders
from healthy anxiety?
Anxiety out of proportion to actual
threat which causes significant distress
or impairment
criteria for GAD?
Six months of excessive anxiety and
worry, more days than not, that are
difficult to control. Plus three or
more of the following:
Restlessness
Fatigue
Tension
Sleep disturbance
Irritability
Decreased concentration
Note: The worry may not be about
symptoms of another disorder, eg,
worrying about having a panic
attack is panic disorder, not GAD.
103
What GI disease is associated
with GAD?
Irritable bowel syndrome; 50% of
patients also have GAD.
What is the male to female ratio of
GAD prevalence?
1:2
What are important nonpsychiatric
differentials to consider for GAD?
Substance-induced anxiety
Substance withdrawal anxiety
General medical conditions
Pheochromocytoma
Hyperthyroidism
Electrolyte abnormalities
What is the initial pharmacological
treatment for GAD?
Selective serotonin reuptake inhibitor
(SSRI)
Venlafaxine
Buspirone
Mirtazapine
What medications give rapid relief,
but have significant long-term abuse
potential?
Benzodiazepines
PANIC DISORDER
What are the DSM-IV-TR criteria for a
panic attack?
Four or more symptoms, which come
up abruptly:
Anxiety
Palpitations
Sweating
Dizziness
Trembling
Shortness of breath
Chest pain
Nausea
Feeling of choking
Chills
Fear of dying
Fear of going crazy or losing control
Feeling detached from one’s self
What characterizes panic disorder?
Recurrent spontaneous panic attacks
and anxiety about future attacks, their
implications, or changing behavior to
avoid attacks
Anxiety Disorders 105
What differentiates panic attacks from
panic disorders?
A panic disorder develops when the
patient has recurrent panic attacks and
has anticipatory fear about future panic
attacks.
What is the male to female ratio for
panic disorder?
1:3
What is the age of onset of panic
disorder?
Mid-twenties
Is family history of panic disorders
relevant?
Yes. Evidence does support an
upregulation of adrenergic output
responsible for stimulating anxiety
centers in the brain which predisposes
certain people to panic attacks.
What are the most common psychiatric
sequelae of panic attacks?
Agoraphobia. Patients have anticipatory
fear which prevents them from venturing
outside alone.
What is the most effective psychotherapy
for panic disorder?
Cognitive behavioral therapy including
relaxation techniques
What is the pharmacologic treatment
of panic disorder?
SSRIs (first-line)
Tricyclic antidepressant (TCA),
monoamine oxidase inhibitors (MAOIs)
(second-line)
What are the important nonpsychiatric
differential diagnoses for panic
disorders?
Arrhythmias
What phobia may occur with
Panic Disorder?
Agoraphobia
Angina
Hypoxia
Hyperthyroidism
Substance-induced intoxication or
withdrawal
OBSESSIVE-COMPULSIVE DISORDER
obsessive-compulsive disorder (OCD)?
Presence of obsessions and/or compulsive
behavior that are time consuming and
cause significant distress or impairment
of functioning
What is an obsession?
Persistent, recurrent thoughts which
cause irrational anxiety
What is a compulsion?
A repetitive behavior that reduces
anxiety—behavior may not be directly
related to the obsession
What differentiates OCD from
obsessive-compulsive personality
disorder (OCPD)?
OCD patients are aware that their
anxiety and compulsions are
unreasonable. OCPD patients are
orderly, inflexible, and perfectionistic—
but see nothing wrong with it.
What is the male to female ratio
for OCD?
1:1
What is the age of onset of OCD?
Late adolescence to early adulthood
What common psychiatric diagnoses
are associated with OCD?
Major depression
Generalized Anxiety Disorder
Tourette syndrome
Note: It is common for patients with
Tourette to have OCD, but it is not
nearly as common for patients with
OCD to have Tourette.
for OCD?
Cognitive-behavioral therapy
(exposure-response prevention,
flooding, thought stopping)
of OCD?
High-dose SSRI (first-line treatment)
What are the important differential
diagnoses for OCD?
Specific phobia
GAD
Body dimorphic disorder
Trichotillomania
Clomipramine (second-line treatment)
SOCIAL PHOBIA
What are the diagnostic criteria
for social phobia?
Persistent fear of social situations
Anxiety or panic attack when exposed
to social situation
Avoidance or distress of feared situation
results in functional impairment
What characterizes social phobias?
Excessive, irrational fear of public or
social situations, in which the patient
could be scrutinized for his or her
performance.
What differentiates social phobias
from specific phobias?
Social phobias involve fear of public
situations where scrutiny could occur.
On the other hand, specific phobias
involve fear of specific objects or
situations not associated with scrutiny.
for social phobia?
1:1
What is the age of onset of
social phobias?
Adolescence following childhood
shyness
What are the most common
social phobias?
Fear of public speaking
What is the most effective
psychotherapy for social phobias?
Cognitive-behavioral therapy including
relaxation techniques
of social phobias?
SSRIs (first-line treatment)
Beta-blockers
What medications are effective
for immediate relief of symptoms,
but must be used cautiously?
Benzodiazepines—should be avoided in
those with substance abuse potential
What are the important differential
diagnoses for social phobia?
Specific phobias
Panic disorder
OCD
Fear of public performances
Fear of answering questions in class
POSTTRAUMATIC STRESS DISORDER
What are the DSM-IV-TR criteria for
posttraumatic stress disorder (PTSD)?
Exposure to a traumatic event involving
threat to self or others, plus 1 month of:
Reexperiencing the event (flashbacks,
dreams, reliving the trauma, etc)
Avoidance of situations and thoughts
associated with the trauma
Increased arousal
What is increased arousal in PTSD?
Anger or irritability
Insomnia
Hypervigilance
Increased startle response
Difficulty concentrating
Note: Diagnosis requires two or more
of above.
What differentiates PTSD from acute
stress disorder?
Patients with PTSD have symptoms for
>1 month that can begin >1 month after
the traumatic event occurs. Patients
with acute stress disorder have symptoms
lasting from 2 days to 1 month which
begin within 1 month of traumatic
event.
What differentiates PTSD from
adjustment disorder?
PTSD involves life-threatening events
(rape, war, etc)
Adjustment disorders involve non-lifethreatening events (divorce, death of
others)
for PTSD?
1:2
How is PTSD classified?
Acute PTSD: Symptoms last <3 months.
Chronic PTSD: Symptoms last
>3 months.
Delayed-onset PTSD: Symptoms begin
>6 months after the life-threatening
event.
for PTSD?
Cognitive-behavioral therapy (CBT)
and support groups
of PTSD?
SSRIs (first-line treatment)
What medication is particularly effective
for PTSD nightmares?
Prazosin (alpha-blocker)
What are important differential
diagnoses for PTSD?
Acute stress disorder
Adjustment disorder
OCD
Malingering
Mood stabilizers
SPECIFIC PHOBIA
What are the symptoms of a specific
phobia?
Fear of specific situations
Anxiety
Palpitations
Sweating
Headache
Restlessness
What characterizes specific phobias?
Excessive, irrational fear of specific
objects or situations
What differentiates specific phobias
from social phobias?
Specific phobias involve fear of specific
objections or situations not associated
with being scrutinized.
What is the male to female ratio for
specific phobia?
1:2
What is the age of onset of specific
phobias?
Mostly childhood but can begin at
anytime
What are the most common types of
specific phobias?
Animals
Storms
Heights
Illness
Injury
for specific phobias?
Flooding
Gradual desensitization
Hypnosis
CBT
of specific phobias?
Benzodiazepines for certain phobias
such as flying
diagnoses for specific phobias?
Social phobia
OCD
GAD
Panic disorder
ADJUSTMENT DISORDER WITH ANXIETY
What is the main characteristic of
adjustment disorder with anxiety?
Emotional or behavioral symptoms
associated with an identifiable stressor
During what time period should the
symptoms present after stressor occurs?
Within 3 months of initial stressor
When should symptoms of adjustment
disorder with anxiety resolve?
Within 6 months of initial symptoms if
stressor removed
What are common causes of adjustment
disorder?
Divorce
Relocation
Attending a new school
What should be ruled out before
diagnosing adjustment disorders?
Bereavement
Any Axis I diagnosis
How does adjustment disorder with
anxiety present?
Occupational impairment
Social impairment
Scholastic impairment
diagnoses?
Bereavement
Acute stress disorder
PTSD
CLINICAL VIGNETTES
A 47-year-old woman describes herself as a “worrier for most of my life.” She
doesn’t worry about anything in particular, but she lays awake at night thinking
about things. It’s exhausting and she can’t seem to get anything else done—of
course, it doesn’t help that she can’t concentrate anyway. What is the most likely
diagnosis?
Generalized Anxiety Disorder
A 32-year-old man was involved in an industrial accident that killed his best
friend. He was right next to him when it happened, and he remembers every bit of
it. In fact, sometimes he feels like he relives it. He has recurrent nightmares about
the event, can’t seem to get to sleep, and can’t face going back to work.
PTSD
How would you treat his nightmares?
His nightmares may be responsive to medical therapy with Prazosin.
A 26-year-old female presents to your clinic with complaints about episodes of shortness
of breath, palpitations, tingling around her mouth, and blurry vision. She has only
experienced two of these episodes, but she fears that she may have more. She asks
you to start her on some medication to help with these fears and the episodes
themselves. Her last menstrual period was 7 weeks ago, and she has a history of
cocaine abuse.
What class of medication would be most useful in providing immediate relief
of symptoms for this patient?
Benzodiazepine
Why might this class of medications be contraindicated in this patient?
She may be pregnant (most benzodiazepines are pregnancy category D) and has
a history of substance abuse making treatment with benzodiazepines problematic.
CHAPTER 15
Cognitive Disorders
Name the three major categories
of cognitive disorders.
1. Delirium
2. Dementia
3. Amnestic disorders
DELIRIUM
What is delirium?
Delirium is a disturbance of consciousness
and attention that usually develops over
a short period of time. The confusion
and memory impairment is not better
accounted for by a preexisting dementia.
What causes delirium?
Any disorder that causes a disruption
of brain physiology, most commonly a
medical or surgical condition, medication.
The cause is often multifactorial. Elderly
patients and those with underlying
dementia are at higher risk.
While most substances of abuse can
cause delirium with acute intoxication,
which three are most likely to cause
delirium related to withdrawal?
Alcohol (delirium tremens),
benzodiazepines, and barbiturates
What factors predispose to delirium?
Acute medical illness
Age: elderly and young children
Preexisting brain damage: dementia,
cerebrovascular disease, tumor
A history of delirium
Advanced Cancer
What are some medications physicians
give patients that contribute
to delirium?
A long list, including:
Anticholinergics (including Benadryl)
Benzodiazepines
Levodopa and other dopaminergics
Opioids
Cardiac medications, eg, Beta-Blockers
Many antibiotics
111
How common is delirium?
Very common. Roughly 15% to 20% of
general hospital patients will have an
episode of delirium. In patients over the
age of 65, the prevalence can be as high
as 30%!
Clinically, what is the hallmark
of delirium?
Altered level of consciousness
(especially attention and level of
arousal). It typically develops over a
period of hours to days and mental
status alterations wax and wane during
the day, with periods of lucidity.
In addition to alterations in
consciousness, what other features
are often found in a patient
with delirium?
Altered sleep-wake cycle
Perceptual disturbance
Impaired memory and orientation
Nocturnal worsening of symptoms
Psychomotor agitation
How do you test for delirium?
Though there is no lab test for delirium,
a good cognitive tool like the minimental status examination can help
identify delirium. Cognitive disturbance
from delirium tends to fluctuate.
How do you treat delirium?
Treat any medical cause, stop medications
that may be contributing (if possible),
orient the patient frequently, and place
in a well-lit room during the day.
While treating the cause of a delirium,
how do you manage a delirious
patient?
Low doses of antipsychotics, like
haloperidol or an atypical antipsychotic
can be helpful for agitation and
hallucinations.
DEMENTIA
What is the core symptom of dementia?
Memory impairment
In order to diagnose dementia, what
must be present in addition to memory
impairment?
At least one of the following:
Aphasia (language and naming problems)
Apraxia (impaired ability to do learned
motor tasks, like using objects)
Agnosia (difficulty recognizing or
identifying objects)
Disturbance of executive function (the
ability to plan, organize, and carry out
tasks, judgment)
Cognitive Disorders 113
How does dementia differ from the
normal memory changes of aging?
As we age, we are less able to learn new
information, and we process information
at a slower speed.
However, these changes do not normally
interfere with the basic functioning.
When diagnosing dementia, what other
disorders in your differential are key
to rule out?
It is crucial that you do not miss a
delirium or a depression. In the elderly,
it is not uncommon for them to report
multiple memory complaints. If you
misdiagnose this as dementia, you will
miss a potentially reversible cause of
memory impairment. Likewise, if you
miss a delirium, you may miss a
potentially serious medical problem.
Additionally, there are several potentially
reversible causes of dementia that you
should look for, including: neurosyphilis,
vitamin B12, thiamine, and folate
deficiencies, and normal pressure
hydrocephalus.
What is the prevalence of dementia?
Incidence/prevalence increases with
age. The prevalence is approximately
1.5 % in those over 65 years of age. The
prevalence increases to 20% after age 85.
What is the most common type
of dementia?
Alzheimer Disease (AD) represents
about 50% to 60% of dementias. The
second most common form is vascular
dementia (formerly multi-infarct
dementia)
Others include front temporal (Pick
and Creutzfeldt-Jakob), Parkinson,
Huntington, and human
immunodeficiency virus (HIV)
dementias.
What is the classical clinical course
for Alzheimer disease?
Slow, gradual onset of memory loss
and cognitive impairment (often there
are problems with judgment, mood
symptoms, and behavioral disturbances
as well). The disease is progressive and
death usually occurs within 3 years
after diagnosis.
How does this differ from the course
of vascular dementia?
Vascular dementia classically has a
stepwise decline, as opposed to the slow
and steady decline in Alzheimer. Onset
of deficits may be abrupt, and with good
control of cardiovascular risk factors the
course may remain relatively stable.
What are the major risk factors for
Alzheimer disease?
Age, family history, Apo E4 allele, and
Down syndrome
On postmortem examination, what
changes are normally seen in the
brain of an Alzheimer disease patient?
Neurofibrillary tangles and senile
(amyloid) plaques
What areas of the brain show cell loss
in Alzheimer disease?
While there is also often global cortical
atrophy, neuronal degeneration is
classically in the cholinergic neurons
of the nucleus basalis of Meynert.
What class of medications is used
to slow the progression of Alzheimer
disease?
Cholinesterase inhibitors such as
donepezil, rivastigmine, and
galantamine may be used. Memantine
(Namenda) is an NMDA (N-methyl-Daspartate) receptor antagonist that
shows promise for slowing progression
in AD.
Table 15.1 Delirium vs Dementia
Delirium
Dementia
Onset
Develops quickly (hours to days)
Develops over weeks
to years
Key feature
Impaired attention and level of
consciousness
Impaired memory
with normal level
of consciousness
Course
Fluctuates within the course
of a day with lucid periods
Worsens at night
Usually stable within
a day
May worsen at night
(sundowning)
Occurrence
Most common in elderly and
young children
Increases with age
Psychiatric
Symptoms
Hallucinations and delusions
may be present
Hallucinations and
delusions may be
present
Physical
findings
Abnormal EEG
Acute medical illness
Normal EEG
No acute medical
illness
Prognosis
Symptoms tend to resolve with
treatment of underlying cause
Usually progressive
Cognitive Disorders 115
AMNESTIC SYNDROMES
How do amnestic syndromes differ
from dementia?
In amnestic syndromes, the disturbance
of function is isolated to memory, while
other cognitive functions remain
relatively intact (unlike dementia).
Which brain structures are affected
in amnestic syndromes?
The bilateral mediotemporal structures
(eg, mammillary bodies, hippocampus,
fornix)
Damage to mediotemporal structures
is associated with what vitamin
deficiency?
Thiamine deficiency. Often this is
related with chronic alcohol abuse
(Korsakoff syndrome)
Name at least four other etiologies
of amnestic syndromes.
1.
2.
3.
4.
Traumatic brain injury
Herpes encephalitis
Cerebrovascular disease
Hypoxia
CLINICAL VIGNETTES
A 79-year-old African American woman has dementia. Her son has heard about the
genetic basis for Alzheimer disease and is worried about his risk of developing the
disease. Looking over her chart you see that she was high functioning 10 years prior
and then first suddenly became rather mildly cognitively impaired about 7 years
ago. She continued at that level until 5 years ago when she developed significant
memory problems and needed some part-time help at home. Two years ago she
again got worse and required assisted living. What do you tell her son about his
risks of Alzheimer disease?
His risk is the same as the normal population. The patient’s history with a
“stepwise decline” is suggestive of vascular dementia, not AD.
You are on the psychiatric consult service and called to see a psychotic patient in
the ICU. The resident there tells you that the patient—a 57-year-old woman with
no prior psychiatric history—is having new-onset schizophrenia. She seemed fine
this morning, but this evening she has hallucinations and is yelling at the nursing
staff. What is the likely diagnosis in this patient? What can be done to help, aside
from medications?
This patient most likely has delirium and almost absolutely does not have
schizophrenia. You should be wary of diagnosing an older individual with a newonset psychotic disorder, especially when underlying medical illness is actively
involved. Delirium is so common in acutely sick patients that it is called “ICU
psychosis.” First and foremost, trying to alleviate the medical condition (or stopping
the offending medication) which has precipitated the delirium is the first course
of action. Environmental factors may help, such as cues to help orient patients to
time, date, and place.
A 57-year-old man with a history of end-stage liver disease and peptic ulcers
underwent surgery to repair a perforated ulcer 2 days ago. He is agitated, confused,
and he believes bugs are crawling on him. He appears floridly delirious and you
begin his workup. His blood work reveals no evidence of infection, his blood
pressure is becoming more labile, and heart rate is increasing. Your attending
physician shows up and is very concerned that he may seize. What is the most
likely etiology for the delirium?
Alcohol withdrawal
CHAPTER 16
Somatoform Disorders
Somatization disorder
Conversion disorder
Hypochondriasis
Body dysmorphic disorder
What are the primary types
of somatoform disorders?
Pain disorder
What is factitious disorder?
A disease in which the patient
intentionally feigns illness to assume
the sick role, but with no other obvious
motivation (aka Munchausen
syndrome)
What is malingering?
Intentional feigning of illness for the
purpose of gaining a conscious reward
What is the primary difference between
somatoform disorders and factitious
disorder or malingering?
Somatoform disorders are unconscious
behaviors, whereas behaviors in
factitious disorders and malingering
are consciously derived by the patient.
Table 16.1
Conscious Behavior?
Motivation Apparent?
Somatoform
No
No
Conversion
No
Yes
Factitious
Yes
No
Malingering
Yes
Yes
No. Disease etiology must be ruled out
in these patients; however, there is no
medical condition that can account for
their symptoms.
Are there any physical examination
findings which are common
in somatoform disorders?
117
What are some disorders with
nonspecific symptoms that should
be thought of before somatoform
disorder is diagnosed?
SLE, Multiple Sclerosis, Myasthenia
gravis, Hyperparathyroidism, Thyroid
disturbance, Porphyria, Malignancy
Should patients with somatoform
disorders be told that they are
imagining their symptoms?
No. Supportive treatment with
suggestions that psychotherapy may
alleviate their distress is associated with
a better prognosis. Remember that pain
is a subjective experience.
What is a good way to frame
the possibility of a lack of general
medical problem?
Reassurance that there is no serious
underlying medical cause, but without
dismissing their symptoms—this may
alleviate some anxiety.
What is a good statement to make
when discussing the possibility
of psychiatric treatment with a patient?
“Many of my patients with similar
symptoms have found a lot of benefit
from...” [SSRIs, psychotherapy, etc]
SOMATIZATION DISORDER
What are the diagnostic criteria
of complaints seen in somatization
disorder?
Patients must manifest four pain,
two gastrointestinal, one sexual, and
one neurologic symptoms, all of which
cannot be fully explained by medical
etiology.
What is the age of onset of
somatization disorder?
Somatic complaints must begin prior
to age 30.
What are common patterns of behaviors
seen in these patients?
These patients often have had multiple
exploratory surgeries and visit multiple
doctors.
Can the symptoms occur in the presence
of a true medical condition?
Yes, however, the complaints will often
be in excess of what would be normally
expected.
What is the prevalence of somatization
disorders in the United States?
0.2% to 2% in women and <0.2% in men
What are risk factors for somatization
disorder?
High socioeconomic status
History of abusive and failed relationships
Family history of somatization
What is the most common first
manifestation of this disorder
in women?
Complaints relating to menses
Somatoform Disorders 119
What is the treatment for somatization
disorders?
Regular brief appointments with the
primary care provider are often useful
in reassuring these patients. Unnecessary
laboratory tests or procedures should not
be performed. In addition, psychotherapy
may be used.
CONVERSION DISORDER
From which body system are
complaints derived from in
conversion disorders?
Neurologic (motor and/or sensory)
What are the most common
manifestations seen?
Sudden onset of blindness
Paralysis
Paresthesias
Seizures
What is a common presentation?
Dramatic onset of symptoms that are
often physiologically impossible
What are common findings on physical
examination of these patients?
Abnormalities do not have anatomical
distribution and neurologic examination
is normal.
What is a common association
with the onset or exacerbation
of symptoms?
Often stressful life events precede the
development of symptoms.
What medical disorder can present
similarly to a conversion disorder?
Multiple sclerosis
What percentage of individuals
diagnosed with a conversion disorder
in fact have a true neurological
condition?
Very few—approximately 4%
Do patients with true conversion
disorders sustain injury as a result
of their condition?
No. Patients with sudden onset of
blindness do not run into objects,
and those with paralysis may still
inadvertently move when distracted.
Are patients with conversion disorder
distressed over their condition?
No. These patients are often calm
regarding their pseudoneurologic
deficits, termed la belle indifference.
Note: This is not diagnostic of conversion
disorder.
Do patients with conversion disorder
intentionally derive any gain from
their symptoms?
No
What is the prognosis and duration
of symptoms seen in conversion
disorders?
Symptoms typically remit within 2 weeks,
with favorable prognosis seen in paralysis
and blindness, and a poor prognosis
associated with seizures.
What is the treatment for conversion
disorders?
Reassurance that the symptoms will
improve usually results in resolution of
the symptoms (self-limiting), however,
conversion disorder often reoccurs later.
Psychotherapy can be helpful.
HYPOCHONDRIASIS
What is the main characteristic
of hypochondriasis?
Preoccupation with having a serious
disease, despite medical reassurance
of health status
Are there true physical symptoms
seen in this disorder?
Yes, however, the symptoms are
misinterpreted by the patient as being
of a greater significance.
What are the most common presenting
symptoms seen in hypochondriasis?
Nausea
Abdominal pain
Chest pain
Palpitations
Is there a gender predominance seen
in hypochondriasis?
No, men and women are equally
affected.
What are common associations with
the development of hypochondriasis?
Often the person has experienced
serious illness in childhood or knows
someone who has died or suffered
through a serious medical condition.
What are common behaviors seen
in these patients?
Doctor shopping is common, as these
patients are resistant to suggestions that
there is no significant medical etiology
to their symptoms.
What is the prevalence of
hypochondriasis?
1% to 5%
What is the treatment for
hypochondriasis?
Group therapy and frequent reassurance
with regular but brief visits to primary
care physician
BODY DYSMORPHIC DISORDER
What is the main characteristic
of body dysmorphic disorder?
Preoccupation with a defect in physical
appearance
Is the defect always imagined
by the patient?
No. In some patients the defect may be
imagined, but in others an exaggeration
of a true physical feature may be present.
What are the two components of body
dysmorphic disorder?
1. Perceptual: Perceptual relates to the
accuracy of the individual’s body.
2. Attitudinal: Attitudinal relates to the
feelings the person has toward his or
her body.
What are risk factors for the development
of body dysmorphic disorder?
Family history of a mood disorder or
obsessive-compulsive disorder
Where do these patients often present?
Often these patients present to
dermatologist and plastic surgeons.
What are the most common features
viewed as defective in these patients?
Facial features
What is the most common comorbid
psychiatric disorder associated with
body dysmorphic disorder?
Depression
What are some common behaviors
seen in this disorder?
Excessive grooming
Avoidance of mirrors
Excessive exercise
Avoidance of public activities
What other diagnoses must be
considered in the differential?
Anorexia nervosa
Gender identity disorder
Narcissistic personality disorder
Do surgical procedures and alterations
tend to improve the patient’s view
of his or her physical defect?
No. These treatments tend to worsen
the disorder, leading to intensified or
new preoccupations with physical
appearance.
What is the recommended treatment
for body dysmorphic disorder?
Antidepressants (such as selective
serotonin reuptake inhibitors [SSRIs])
(only if comorbid mental illnesses such
as depression or anxiety are present)
and cognitive behavioral therapy
Hair
Body build
FACTITIOUS DISORDER
of factitious disorder?
Intentional simulation of illness
Are patients with factitious disorder
or malingering aware of the false
nature of their somatic complaints?
Yes. This is the distinguishing
characteristic between factitious
and somatoform disorders.
How is factitious disorder different
from malingering?
The only obvious conscious goal of
factitious disorder is to assume the “sick
role”—there is no clear benefit or gain.
Which gender is more prevalent
in factitious disorders?
Female
What occupation has the highest
prevalence of factitious disorders?
Health-care workers
What disease presentations are often
seen in factitious disorder?
Hematuria (from adding blood to urine
or from the use of anticoagulants) and
hypoglycemia (from insulin injection)
What laboratory finding would indicate
self-injection of insulin?
Low C-peptide level
What are common behaviors seen in
patients with factitious disorder?
Requests for analgesics
Extensive knowledge of medical
terminology
Eager desire to undergo medical
procedures and operations
Traveling to different locations,
hospitals, emergency rooms, etc
What are common histories of patients
with factitious disorder?
Patients often have dramatic histories
with extensive details about their
symptoms.
What is the appropriate treatment
for factitious disorder?
Recognition and confrontation in a
nonaccusatory manner
What is the prevalence of factitious
disorder?
0.5% to 0.8%—very difficult to determine
Which gender is most commonly seen
in factitious disorder?
Females
What is a well-known variant
of factitious disorder?
Factitious disorder by proxy (aka
Munchausen syndrome by proxy)
of factitious disorder by proxy?
Intentional simulation of illness in
another person
Who is the most common
perpetrator seen in factitious
disorder by proxy?
A parent (most often a mother) often
stimulating illness in her child
What is the treatment for factitious
disorder by proxy?
Same as in factitious disorder, however,
if a child is involved, the case should be
managed as child abuse and reported to
the appropriate agencies.
MALINGERING
of malingering?
Intentional production of symptoms for
secondary gain
How is malingering different from
factitious disorder?
The goal of malingering is to obtain a
concrete or material gain.
What are common scenarios in which
malingering is often seen?
Individuals wanting to avoid jail time
or military recruitment, seeking financial
compensation, etc
Which gender is most prevalent
in malingering?
Males
What is Ganser syndrome?
A variant of malingering in which
patients give ridiculous answers to
questions in order to avoid
responsibility for their actions
In what populations is Ganser
syndrome most commonly seen?
Prison inmates
CLINICAL VIGNETTES
A 71-year-old man comes to your office for evaluation of a right foot paralysis. He
complains that he is unable to move his right foot ever since he was involved in a
car accident, during which he was driving and the teenaged passenger of the other
vehicle was seriously injured. His neurologic examination is normal. What is the
most likely diagnosis?
Conversion disorder. Note the stressful event, normal neurologic examination,
and the fact that it is his driving foot that is affected.
A 26-year-old female nurse is admitted after being found by a friend unconscious
in the hallway. On finger stick, her glucose is 17. She has no history of diabetes.
What psychiatric disorder might you suspect if medical workup is negative?
Factitious disorder. Note conscious behavior (likely insulin overdose), but no
obvious motivation/gain.
What laboratory testing can you do, and how would it support your diagnosis?
A C-peptide level would be useful, and if it was low you would suspect exogenous
insulin overdose, therefore supporting your diagnosis.
A 37-year-old man presents to the ED complaining of “10/10 right flank pain
radiating to the testicle.” He specifically requests 2 mg of IV hydromorphone and
states he is allergic to both NSAIDs and Tylenol. A nurse reports that she saw him
putting drops of blood into his urine collection cup. What is the most likely
diagnosis?
Malingering
A 12-year-old girl and her parents present to your office with a chief complaint of
dysphagia for 3 days. According to the girl’s parents, who are very concerned and
anxious, the girl choked while eating lunch 3 days ago and the Heimlich maneuver
was performed to expel the food. Since then she has been unable to swallow any
solids or liquids. Additionally, she is unable to swallow any of her normal oral
secretions, and has been spitting constantly in a container. On examination, the
girl is very quiet, calm, and somewhat unconcerned about her condition.
Assuming physical examination is normal and an upper gastrointestinal (GI)
series fails to reveal any pathology, what is the likely diagnosis?
Conversion disorder
CHAPTER 17
Personality Disorders
What is personality?
Personality is “the set of characteristics
that defines the behavior, thoughts, and
emotions of individuals,” and is
persistent over time.
What constitutes a personality
disorder?
Personality disorders occur when
a particular feature or trait of an
individual’s personality becomes
inflexible or maladaptive and impairs
social, occupational, or personal
functioning.
What diagnostic criteria are common
to all personality disorders?
The patterns are pervasive and
begin by early adulthood, lead to
significant distress or impairment,
and are not better explained by an
Axis I disorder.
Which axis of the DSM-IV-TR
do personality disorder
diagnoses fall under?
They are Axis II diagnoses.
How are the personality disorders
divided?
Into clusters—A, B, and C
Which personality disorders fall
under cluster A?
Paranoid, schizoid, and schizotypal
What is the common theme among
cluster A disorders?
They are considered odd or eccentric
traits.
Which personality disorders fall under
cluster B?
Histrionic, narcissistic, antisocial, and
borderline
cluster B disorders?
They are described as dramatic,
emotional, and erratic.
125
cluster C?
Avoidant, dependent, and
obsessive-compulsive
cluster C disorders?
They tend to be anxious and fearful.
What is a good way to remember these
clusters?
They are Mad, Bad, and Sad.
A = Mad, B = Bad, C = Sad.
CLUSTER A: THE MAD
How is schizoid personality disorder
described?
Patients have “a pervasive pattern of
detachment from social relationships
and a restricted range of expression of
emotions in interpersonal settings.”
What are the symptoms/criteria for
schizoid personality disorder ?
Four or more of the following:
No desire or enjoyment of close
relationships
Choice of solitary activities
Little interest in having sexual experiences
Enjoyment of few activities
Lack of close friends
Apparent indifference
Emotional coldness/detachment/
flattened affect
How is paranoid personality disorder
defined?
Paranoid personality disorder involves
a “pervasive and unwarranted suspicion
and mistrust of people, hypersensitivity
to others, and an inability to deal with
feelings.”
What are the criteria/symptoms
of paranoid personality disorder?
Suspicion of exploitation or
deceitfulness on the part of others
Preoccupation with unjustified doubts
Reluctance to confide in others
Reading hidden demeanings or
threatening meanings into benign
remarks or events
Persistently bearing grudges
Perception of attacks on his or her
character or reputation to which he
or she reacts quickly/angrily
Recurrent suspicions
Personality Disorders 127
What is the best treatment for paranoid
personality disorder?
Psychotherapy and possibly
antipsychotic medications to manage
agitation and paranoia (overt delusions
are not usually seen)
How is schizotypal personality disorder
defined?
Patients with schizotypal personality
disorder are usually described as strange
or odd in behavior, appearance, and/or
thinking. However, they are neither
frankly delusional nor psychotic.
Ideas of reference
Odd beliefs/magical thinking/believe
that they have “special powers”
Unusual perceptual experiences
What are the symptoms of schizotypal
Odd thinking and speech
Suspiciousness/paranoia
Inappropriate/constricted affect
Odd behavior/appearance
Lack of close friends
Excessive social anxiety
What percentage of patients with
Schizotypal Personality Disorder
go on to develop schizophrenia?
10% to 20%—ie, most do not
CLUSTER B: THE BAD
cluster B?
Histrionic, narcissistic, antisocial,
and borderline
cluster B disorders?
They are described as dramatic,
emotional, and erratic.
What other psychiatric diagnoses
do patients with cluster B disorders
often carry?
Mood disorders are quite prevalent,
as well as somatization disorders,
and substance abuse/dependence
How are patients with antisocial
personality disorder usually described?
Charming, but manipulative. They often
have a history of criminal activities and
many have a history of substance abuse.
They show no remorse for their actions,
even if others are harmed.
What prior childhood diagnosis must
have been present in order to be
diagnosed with antisocial personality
disorder as an adult?
Conduct disorder
antisocial personality disorder?
Three or more of the following:
Failure to conform to social norms and
laws
Deceitfulness
Impulsivity
Irritability and aggressiveness
Disregard for the safety of self
or others
Irresponsibility (often unemployment)
Lack of remorse for harm to others
What is the best treatment of antisocial
Group therapy with setting of
boundaries for behavior, selective
serotonin reuptake inhibitors
(SSRIs), and treatment of underlying
substance abuse/misuse
if present.
These individuals are very refractory
to treatment.
How is borderline personality
disorder defined?
Borderline personality disorder involves
the primary feature of instability. This is
seen in terms of the patient’s self-image,
interpersonal relationships, and mood.
(Think Angelina Jolie’s character in
Girl Interrupted.)
What defense mechanism is prevalent
in patients with borderline personality
disorder?
Splitting—eg, people are either all good
or all bad.
What are the symptoms/diagnostic
criteria of borderline personality
disorder?
Five or more of the following:
Frantic efforts to avoid real or imagined
abandonment
Unstable or intense interpersonal
relationships
Identity disturbance, impulsivity
Recurrent suicidal or self-mutilating
behavior
Marked reactivity of mood
Chronic feelings of emptiness
Inappropriate/intense anger
Lack of control of anger
Transient stress-related paranoid
ideation
What are the most prevalent symptoms
of borderline personality disorder?
Unstable relationships and mood/
affect lability
What developmental characteristics
are often present in patients
with borderline personality
disorder?
Many were severely abused as children.
What is the best treatment for borderline
Psychotherapy and mood stabilization
with either antidepressants,
carbamazepine, or valproate.
Patients may also require shortterm antipsychotics for treatment
of psychosis.
What drug class should be avoided in
patients with borderline personality
disorder?
Benzodiazepines, because of addictive
potential and with overdose
How is narcissistic personality disorder
described?
Narcissistic personality disorder is
defined as a grandiose sense of selfimportance along with extreme
sensitivity to criticism. These patients
have “little ability to sympathize with
others, and are more concerned about
appearance than substance.” (Think Bill
Murray’s character in Groundhog Day.)
criteria of narcissistic personality
disorder?
Grandiose sense of self-importance/
exaggeration of achievements and
talents
Preoccupations with ideals of success,
power, brilliance, beauty, or love
Belief that he or she is special or unique,
and can only be understood or
appreciated by high-status individuals
Sense of entitlement
Lacks empathy for others
Manipulative or exploitive of others
Requires excessive admiration
Believes others envy him or her,
or envies others
Arrogant
What other psychiatric conditions
are associated with narcissistic
Mood disorders and other cluster
B traits
What is the best treatment of
narcissistic personality disorder?
Psychotherapy (either group or
individual)
How is histrionic personality disorder
described?
Histrionic personality disorder can be
identified by the flamboyant/attentionseeking behaviors of patients. They are
extremely emotional, and may present
as very attractive and seductive.
(Think Scarlett O’Hara in Gone with
the Wind.)
criteria of histrionic personality
disorder?
Persistent need to be the center of
attention
Inappropriately sexual/seductive/
provocative
Rapidly shifting, shallow emotions
Believes relationships are more intimate
than they actually are
Impressionistic speech lacking detail
Melodramatic
Uses physical appearance to attract
attention
Suggestible/easy to manipulate
What other psychiatric disorders are
often associated with histrionic
Mood disorders and somatization
disorders
What is the best treatment of histrionic
Psychotherapy and antidepressants for
underlying mood disorders
CLUSTER C: THE SAD
How is avoidant personality disorder
often described?
Individuals with avoidant personality
disorder are often shy and timid.
They are very self-critical, have low
self-esteem, and are preoccupied
with fears of rejection or
embarrassment.
What other personality disorder may
avoidant personality disorder be
mistaken for?
Schizoid personality disorder
How can avoidant personality disorder
and schizoid personality disorder be
differentiated?
Patients with avoidant personality
disorder want to have interpersonal
relationships but are afraid of rejection;
whereas, schizoid personality disorder
patients do not wish to have
relationships with others.
criteria of avoidant personality
disorder?
Avoidance of occupations that involve
interaction with others.
Fear of intimacy/lack of intimate
relationships for fear of ridicule.
Unwilling to be involved with people
unless certain of being liked.
Preoccupation with criticism or
rejection.
Believes they are socially inept and
inferior to others.
Feelings of inadequacy inhibit social
involvement.
Reluctance to become involved in new
activities.
What other psychiatric conditions
are often seen in patients with avoidant
Social phobia, specific phobia, and
agoraphobia
What is the best treatment of avoidant
Psychotherapy and assertiveness
training, SSRIs, Beta-Blockers
How is dependent personality disorder
described?
Patients are passive and may let others
direct their lives and make important
decisions. (Think Bill Murray’s
character in What about Bob?)
criteria of dependent personality
disorder?
Inability to make decisions without
advice
Refusal to assume responsibility
Has difficulty expressing disagreement
Difficulty initiating projects
Need for excessive nurturing and
support
Feelings of discomfort and helplessness
when alone
Persistent need to be in a relationship
Unrealistic fears of being left alone
What other psychiatric disorders are
common in individuals with dependent
Depression and anxiety disorders
What is the best treatment for dependent
Psychotherapy and assertiveness
training, treatment of comorbid
conditions
How is obsessive-compulsive
personality disorder described?
Individuals have extreme perfectionist
tendencies and inflexibility, a
preoccupation with orderliness
and control.
How does obsessive-compulsive
personality disorder (OCPD) differ
from obsessive-compulsive disorder
(OCD)?
Individuals with obsessive-compulsive
personality disorder do not have
intrusive thoughts (obsessions) or
actions that they carry out to relieve
the anxiety provoked by those thoughts
(compulsions).
They also do not believe they have a
problem; patients with OCD know their
actions are irrational, whereas OCPD
patients are more likely to think
everyone else has the problem.
criteria of obsessive-compulsive
Four of more of the following:
Preoccupation with rules/details/
organizations—often such that the point
of the activity is lost
Perfectionism
Excessive devotion to work and
productivity
Inflexible about moral or ethical
values
Will not discard unneeded objects
(Pack rats)
Reluctant to delegate to others
Cheap/frugal in order to hoard
money
Rigidity and stubbornness
What is the best treatment for
obsessive-compulsive personality
disorder?
Psychotherapy
CLINICAL VIGNETTES
Your patient is an excellent medical student. He always studies for 6 hours a night,
every night, and at the same time. He checks his orders three times before he turns
them in. He does everything himself because he is convinced no one can do as
good of a job as him. He keeps every note he’s ever written about a patient. No one
else in the class likes him, but he is convinced that’s just because they are jealous
of him—he is just fine. He does not do well and is up for dismissal from medical
school. What is his most likely diagnosis?
Obsessive-compulsive personality disorder
A young man comes into your office complaining of lack of social relationships.
He works alone as a night security guard. He got invited to a work party once, but
was too afraid to go. He would like to make friends, but feels he isn’t worthy of
socializing. He is sure they would only make fun of him anyway. What is the most
likely diagnosis?
Avoidant personality disorder
CHAPTER 18
Dissociative Disorders
of dissociative disorders?
Sudden memory loss of time periods,
events, and people
Detachment from one’s self
Derealization
Blurred sense of identity
What are the four major dissociative
disorders?
1.
2.
3.
4.
Dissociative amnesia
Dissociative fugue
Dissociative identity disorder
Depersonalization disorder
Which conditions are included in the
differential diagnosis of dissociative
disorders?
Substance abuse
Seizure disorders
Which disorder is associated with
an inability to remember important
personal information?
Dissociative amnesia
Which group of people is most
likely to suffer from dissociative
amnesia?
Young adult females
What is the primary trigger for
dissociative amnesia?
Often follows a psychologically
traumatic event
What treatment modality is used
for dissociative amnesia?
Psychotherapy
What disorder is associated with an
inability to remember important
personal information and wandering
away from home to adopt a new
identity?
Dissociative fugue
Head injury
Posttraumatic stress disorder
Malingering
135
How long does it normally take for
the amnesia to resolve in a person
who is experiencing dissociative
amnesia or dissociative fugue?
Minutes or days; may last for years
for dissociative fugue?
Supportive psychotherapy
Hypnosis
Which controversial disorder is
associated with a person having
“multiple personalities”?
Dissociative identity disorder
What are the DSM-IV-TR criteria
for Dissociative Identity Disorder?
Presence of two or more distinct
identities or personality states
At least two of these identities take
control of the persons behavior
Inability to recall personal information
Not due to substance use or a general
medical condition
Which gender is most likely
to develop dissociative identity
disorder?
Female
What conditions may dissociative
identity disorder resemble?
Borderline personality disorder
Schizophrenia
for dissociative identity disorder?
Psychotherapy and hypnotherapy
Which disorder is associated with
repeated episodes of detachment
and unreality about one’s own body,
social situation, or the environment
(derealization)?
Depersonalization disorder
for depersonalization disorder?
Psychotherapy; pharmacologic
interventions utilized for associated
anxiety or depression
CLINICAL VIGNETTES
A war veteran claims he cannot remember the beach assault during which his best
friend was killed. He denies any substance use. What dissociative disorder may
this be?
Dissociative amnesia (Note: This could also be “Post-Traumatic Stress Disorder.”)
Dissociative Disorders 137
A 42-year-old stock broker fails to return home from work one day. Two years later
he is found living in a nearby small town and working as a mechanic at a local
shop. He does not recall any of the past events of his life and denies having ever
been a stock broker. What state is this called?
Dissociative fugue (Think Jason Bourne in the movie/book The Bourne Identity.)
A woman often feels as though she is floating outside of her body, watching her
actions from above. It has started to interfere with her ability to stay employed.
Depersonalization disorder.
What about if this feeling had only happened one time during a time of extreme
danger?
If it had only happened once, this diagnosis cannot be made—dissociative symptoms
are common in life-threatening situations.
A 52-year-old man convicted for murder claims that he does not remember his
crimes. He has been witnessed to apparently be “possessed” by other
personalities, during which he does not remember important information about
himself. What is a possible psychiatric diagnosis and what is on the differential?
Possibly (though very unlikely) dissociative identity disorder. More likely this could
be due to substance use or malingering.
CHAPTER 19
Substance Abuse
Disorders
criteria for substance dependence?
Three or more of the following:
Tolerance.
Withdrawal.
More substance taken than was
intended.
Failure to control use, or a desire to
stop using.
Much time is spent either obtaining
the substance, using the substance,
or recovering from its effects.
Social or occupational activities are
reduced because of use.
Use continues despite physical or
psychological impacts of use.
How is tolerance defined?
Either a need for increased amounts of
substance to achieve the same effect or
diminished effect with use of the same
amount
How is withdrawal defined?
A withdrawal syndrome characteristic
of the drug or the same or similar
substance is taken to avoid that
withdrawal syndrome.
criteria for substance abuse?
Does not meet substance dependence
criteria and one of following:
Substance use results in failure at
work, school, or home.
Recurrent use in hazardous situations
(eg, driving).
Recurrent substance-related legal
problems.
Use despite social or interpersonal
problems made worse by use.
139
What pathway is involved in the
chemical rewards of drug use?
The “dopamine reward pathway” is
thought to play a large role—it projects
from the ventral tegmental area (VTA) to
the nucleus accumbens.
What factors affect how quickly and
to what magnitude the chemical
rewards are felt after ingestion
of a drug?
• Route of administration: The faster
What are the three important
observations about withdrawal
that Himmelsbach made?
1. There is a common association
between tolerance and a specific
withdrawal syndrome.
2. The nature of the withdrawal
syndrome is opposite to the
acute effects of the drug.
3. The withdrawal syndrome is most
intense when the drug leaves the
brain rapidly.
What are the four central tenets
that must be addressed in order
to successfully treat drug dependence?
1. The positive reinforcements/reward
effects of the drug must be reduced.
2. The negative reinforcements
(withdrawal symptoms) must be
treated, either by giving a substitute
drug or by symptomatically treating
the effects of drug removal.
3. Detoxification—complete removal
of the drug of dependence from the
patient’s system.
4. Relapse prevention by reducing the
desire for the drug or by reducing
cravings for the drug.
How should withdrawal symptoms
be prevented/treated during
detoxification?
Withdrawal symptoms may be
prevented/treated by administering
a substitute drug with a similar effect
(eg, methadone for heroin,
benzodiazepines for EtOH), or treating
the withdrawal symptomatically
(eg, treating diarrhea and
GI symptoms).
through the blood-brain barrier,
the greater the euphoria and higher
likelihood of addiction (eg, IV >
smoking > oral [pills])
• Chemical composition of the drug
(increasing purity → increased and
faster effects)
• Genetic differences between people
(relates to receptor stimulation)
• Associated stimuli (ie, drug
paraphernalia, other conditional
stimuli)
Substance Abuse Disorders 141
How can the positive reinforcement
effects of drugs be reduced?
Giving specific receptor antagonists
to prevent the binding of receptors
by the drug of dependence; therefore,
precipitating withdrawal and preventing
the effects of the drug (eg, naloxone or
naltrexone treatment for opiates)
Converting reward to punishment (eg,
the use of disulfiram [Antabuse] for
alcohol dependence)
Giving dopamine or opiate antagonists
to cause general inhibition of the
reward pathways
Negative discriminative stimuli (eg, telling
the patients that their drug of choice
will be ineffective; therefore, they avoid it)
How does disulfiram work?
Disulfiram inhibits aldehyde
dehydrogenase in the liver. Alcohol is
then unable to be fully metabolized,
leading to flushing, headache, and
nausea from accumulation of the
aldehyde intermediate.
What side effect of opiate antagonists
may result in compliance problems?
Anhedonia
What are the three major ways
of reducing withdrawal?
1. Substitute drugs that act as agonists
for the same receptor, and therefore,
prevent severe withdrawal (ie, using
methadone to treat heroin or opiate
dependence)
2. Substitution by partial agonist for the
same receptor, thereby, preventing
severe withdrawal and counteracting
the effects of the drug if it is taken
3. Substitution of a different route of
administration to prevent some of
the adverse effects of the drug itself
while still preventing withdrawal (ie,
using the nicotine patch for smoking
cessation)
What criteria should be used when
selecting a substitute drug for treating
withdrawal?
Substitute drugs should be:
Less rewarding
Less damaging
More manageable
Able to allow the patient to be more
functional (eg, methadone)
What are the major problems with
using positive and negative
reinforcement treatments?
To use positive reinforcement
treatments, the patient must undergo
detoxification first.
Negative reinforcement treatments
may lead to polydrug abuse,
especially if substitution methods
are used.
What is the basic principle behind
detoxification?
Detoxification uses the principle of
substitution with a drug of crossdependence or different route of
administration to allow for safer,
slower withdrawal from the drug
of dependence. It should not be
used to precipitate withdrawal.
What percentage of patients who
become drug-free relapse?
75%—most within the first year
What modalities have been associated
with decreased incidence of relapse?
Joining self-help groups → providing
a different type of peer pressure and
reinforcement
Cognitive therapy → helps develop
new and different coping skills
What is the most likely reason
for relapse?
Cravings is the most common reason
for relapse. Cravings are caused by
memories of the positive rewards of
drug use or by conditioning cues that
are endogenous or exogenous.
How can cravings be treated to prevent
relapse?
Cravings may be treated by reducing
the desire for the drug, providing a
substitute for the drug reward, reducing
endogenous cues for cravings (ie, by
using anxiolytics or antidepressants),
reducing the conditional anticipation
of the reward (ie, giving naltrexone
to an alcoholic), or by reducing
pseudowithdrawal symptoms.
What are some of the medical effects
of drug abuse?
Increased risk of lung disease
and cancer
Increased risk of human
immunodeficiency virus (HIV),
hepatitis, and other infections with
intravenous (IV) drug use
Acute and chronic toxicities
What are some of the nonmedical
consequences of drug abuse?
Sociological problems such as violence,
crime, and poverty
Acute impairment leading to reduced
cognition or restraint
Other risky behaviors (eg, increased
likelihood of sexual violence)
What are the acute symptoms of ethanol
toxicity?
Vomiting (with risk of possible
aspiration due to decreased mental
status)
Respiratory depression
Coma
Death
What are the chronic symptoms
of ethanol toxicity?
Psychiatric symptoms (depression,
hallucinations)
Neurological signs (dementia, vascular
problems, and neuropathies)
GI tract malfunction (cirrhosis of the
liver, pancreatitis, and GI cancer)
Cardiovascular disease (cardiomyopathy,
hypertension)
What are the clinical manifestations
of fetal alcohol syndrome?
Pre- and postnatal retardation of growth
and cognition
Facial abnormalities (short palpebral
fissures, thin vermillion border of the
upper lip, smooth philtrum, and
flattened midface)
Central nervous system (CNS)
damage
Attention deficits
Tendency for risk-taking behaviors, such
as substance abuse
What is the most common form
of drug dependence?
Caffeine dependence, which is seen in
60% to 70% of the population
What are the deleterious effects
of caffeine?
In acute intoxication there can be
cardiovascular side effects
(palpitation, arrhythmia, increase
in BP). Caffeine withdrawal can
cause headache.
However, there is little to no evidence
of adverse effects with chronic, casual
caffeine use.
What is the mechanism of action
of cocaine?
Cocaine is a stimulant that works by
preventing the reuptake of catecholamine
transmitters, such as dopamine and
norepinephrine, in the brain and
autonomic nervous system.
What are the physiologic effects
of cocaine use?
Vasoconstriction
Tachycardia
Hyperthermia
Hypertension
Cardiac dysrhythmias
Stroke
Psychosis
What is the most likely mechanism
of psychosis in chronic cocaine users?
Dopamine potentiation
of amphetamines?
Amphetamines block both the reuptake
of dopamine and norephinephrine at
the synapse, as well as cause the release
of stored catecholamines.
What are the acute and chronic effects
of amphetamine use?
Vasoconstriction
Tachycardia
Hyperthermia
Hypertension
Cardiac dysrhythmias
Stroke
Psychosis
Neurotoxicity
of dissociative anesthetic drugs like
ketamine and phencyclidine?
Dissociative anesthetics work by
blocking N-methyl-D-aspartate (NMDA)
receptors and sigma receptors in the CNS.
What are the effects of dissociative
anesthetic use?
Amnesia
Confusion
Delusions and hallucinations
Violent behavior
Hyperthermia
of marijuana?
Marijuana is a tetrahydrocannabinoid
that works on cannabinoid receptors, a
member of G protein–linked receptors.
These affect monoamine and
γ-aminobutyric acid (GABA) neurons
in the basal ganglia, hippocampus, and
cerebellum.
What are the chronic toxicities
associated with marijuana use?
Poor memory and motivation
Testosterone suppression, gynecomastia
Chronic obstructive pulmonary disease
(COPD)
Immunosuppression
Low fetal birth weight
Where are the opioid receptors located
in the brain and what is the function
of each receptor?
Periaqueductal grey matter →
responsible for analgesia
Area postrema → responsible for nausea
and vomiting
Ventral medulla → responsible for
respiratory depression
Edinger-Westphal nucleus →
responsible for the pinpoint pupil
response (due to extreme miosis)
Nucleus accumbens → responsible for
euphoria
What are the three classic types
of opioid receptors?
1. Mu
2. Kappa
3. Delta
What receptors do most clinically used
opiates such as morphine work on?
Mu
What endogenous peptide transmitters
work at opioid receptor and which
receptors do they act on?
Enkephalins act on mu and delta
receptors, main actions are at delta
receptors.
Beta-endorphins act on mu and delta
receptors equally.
Dynorphins act on kappa receptors.
Describe the mechanism of action
of opioids at their receptors:
Opioid receptors are G protein–coupled
receptors with seven membranespanning segments. Activation of the
receptors causes changes in cyclic
adenosine monophosphate (cAMP),
2+
Ca , etc, leading to inhibition of
neuronal excitation.
How do strong agonists cause
the effects of opioids?
Strong agonists have high affinity
for the receptor and produce a
conformational change that activates
the receptor.
How do antagonists work?
Antagonists have high affinity for the
receptor and do not activate the receptor.
What is the difference between strong
and partial agonists?
Both strong and partial agonists have
high affinity for the receptor; but unlike
strong agonists, partial agonists have
low efficacy to activate the receptor
resulting in a weak effect. Because of
this high affinity/low efficacy, they can
antagonize/block the effects of a
stronger agonist.
What is the difference between opiates
and opioids?
Opiates are derived from the
opium poppy, while opioids
are synthetic or semisynthetic
derivatives of opiates.
How do kappa and mu receptors differ?
The difference between kappa receptors
and mu receptors is that activation of
kappa receptors produces less analgesia,
less respiratory depression/asphyxia
(floor effect), and produce dysphoria
instead of euphoria.
Which opioids/opiates are strong
mu receptor agonists?
Morphine
Fentanyl
Etorphine
Heroin
Hydromorphone
Oxycodone
Meperidine
Which opioids/opiates are partial
mu receptor agonists?
Buprenorphine
What relative of morphine without
sedative effect is used to suppress
cough?
Dextromethorphan
Which opioids/opiates are mu receptor
antagonists?
Nalorphine
Naltrexone (nonnarcotic)
Which opioids/opiates are kappa
receptor antagonists?
Buprenorphine
Naltrexone (nonnarcotic)
What drug can be used as a narcotic
reversal agent?
Naltrexone/Naloxone (aka Narcan)
Which opioids/opiates are metabolized
by CYP2D6?
Oxycodone
Codeine
Pentazocine
What is the significance of being
metabolized by CYP2D6?
In drugs that are metabolized by
CYP2D6, the active metabolite is
morphine.
Which opioid receptor agonist does not
work systemically and can be used as
an antidiarrheal agent?
Loperamide, which works by reducing
GI tract motility
What is the clinical indication for
methadone?
Methadone is used to treat withdrawal
from heroin while acting to decrease
cravings and risk from associated
lifestyle (legal, HIV, hepatitis, etc).
What are the symptoms of narcotic
overdose?
In narcotic overdoses, CO2 drive is
reduced resulting in respiratory
depression and cyanosis and
diminished mental status/coma.
What is the route of absorption
of ethanol in the body?
The very low molecular weight as
well as its water and lipid solubility
allow for rapid absorption of ethanol
from the GI tract and entry into the
brain.
What is the limiting factor in ethanol
absorption?
Absorption of ethanol is limited only
by the surface area of the stomach.
What is the effect of ethanol’s water
solubility?
Its water solubility allows absorbed
ethanol to be distributed throughout
the body water.
of ethanol?
Ethanol’s mechanism is not completely
known, but likely has to do with
alteration of membrane fluidity as
well as actions on GABA receptors,
glutamate NMDA receptors, and
the serotonin system.
What is the physiologic effect of
ethanol’s action on GABA receptors?
GABA is the major inhibitory
transmitter in the brain, and ethanol
potentiation of GABA causes anxiolysis
and possibly the reward effects by
increasing dopamine release from
the nucleus accumbens.
What is the physiologic effect of
ethanol’s action on glutamate receptors?
Glutamate is a major excitatory
transmitter in the brain, and ethanol
inhibits glutamate causing amnesia and
anesthetic effects and possibly reward
effects.
CAGE questions:
Ever felt the need to Cut down your
drinking?
Have you felt Annoyed by criticism
of your drinking?
Ever felt Guilty about your drinking?
Ever taken an Eye opener (a drink first
thing in the morning)?
How many drinks are needed for
an 180-lb man to reach the legal
limit (0.08% blood alcohol content
[BAC])?
Four standard drinks = a BAC of 0.08%
How many drinks are needed for an
140-lb woman to reach the legal limit
(0.08% BAC)?
Three standard drinks = a BAC of 0.10%
(over the legal limit)
How is ethanol eliminated from
the body?
Ninety-five percent of the ethanol
ingested is metabolized in the liver.
How is ethanol metabolized in
the liver?
Alcohol metabolism is a zero-order
process in which alcohol is converted
by alcohol dehydrogenase to aldehydes,
and then the aldehydes are converted
by aldehyde dehydrogenase
to acetate.
What is zero-order elimination
of a drug?
Zero-order elimination occurs when a
constant amount of drug is eliminated
from the body per unit of time,
regardless of the drug dose or
serum concentration.
Concentration of plasma
What is a useful and evidence-based
way to screen for alcohol abuse?
Time (h)
Figure 19.1 Zero-order elimination. (Drug has a constant elimination per unit time, regardless of
concentration.)
Serum drug concentration
Time (h)
Figure 19.2 First-Order Elimination. (Drug elimination is concentration dependent—more is
eliminated as serum concentration is raised.)
What is the limiting factor in ethanol
metabolism by the liver?
The limiting factor in alcohol
metabolism is the availability of
nicotinamide adenine dinucleotide
(NAD) and nicotinamide adenine
dinucleotide plus hydrogen (NADH),
which is used by aldehyde
dehydrogenase.
Which metabolic process is responsible
for the toxic effects of alcohol?
The toxic effects of alcohol are related to
metabolism of alcohol to aldehydes, the
buildup of which causes liver and tissue
damage, flushing, nausea, and
headache.
What are the chronic effects
of alcohol ingestion?
Development of tolerance
Psychological dependence
Physiologic dependence (this includes
tolerance and withdrawal)
Huge host of medical problems,
including liver disease, cancer, etc
What are the three types of tolerance?
1. Metabolic tolerance: allows for
more rapid metabolism and
excretion
2. Behavioral tolerance: involves
learning to perform a task while
intoxicated as if the person is not
intoxicated
3. Neuroadaptation: involves the
evolution of alterations in the brain
that help to overcome the effects of
the drug
What are symptoms of minor
withdrawal from chronic alcohol use?
Minor signs occur early and subside
within 2 days. They include anxiety,
tremulousness, insomnia, GI upset,
palpitations, diaphoresis, and headache.
What are withdrawal seizures?
Tonic-clonic movements occurring from
2-48 hours after the last drink. This may
progress to delirium tremens (DT).
What are alcoholic hallucinations?
Visual, tactile, or auditory hallucinations
from 12-48 hours after the last drink.
Vital signs remain normal.
What is delirium tremens (DTs)?
An alcohol withdrawal syndrome with
hallucinations, altered mental status,
and seizures accompanied by vital
sign abnormalities (tachycardia,
hypertension, fever). Vital sign
abnormalities may be the first clue
to diagnosis. DT may lead to death.
What is the earliest that DTs occur?
48 hours after the last drink, though
may be longer
How is alcohol withdrawal treated?
Benzodiazepines for suppression of
withdrawal symptoms
Vitamins (particularly thiamine) to treat
underlying vitamin deficiencies seen in
long-term alcoholism
Antihypertensives to suppress
underlying hypertension that can
be made worse by the physiologic
withdrawal process
What is the relapse rate in the first year
after alcohol detoxification?
75%
What are the most common reasons
for relapse in alcoholics?
Memories/conditioning
Peer pressure
Genetics
Rapid reinstatement of physiologic
dependence
What types of treatment can be used
to prevent relapse in alcoholics?
Support groups (eg, AA)
Psychological treatment
Pharmacotherapy (naltrexone,
disulfiram, or acamprosate)
CLINICAL VIGNETTES
A 48-year-old man comes in for an elective surgery. His operation is a great success
and there are no major complications. Three days after his surgery he becomes
very disoriented, and yells nonsense at the nurses. His HR is 110, his BP is 154/92,
and he is febrile. His family asks you if there is anything they can do. What is a
key piece of history you could ask the family about?
Ask about his drinking habits. He may be in alcohol withdrawal since he has
likely not had a drink since surgery.
A 26-year-old woman just had her third DUI arrest. She gets drunk every night
with her friends and has never had any regrets about doing it. She has lost four
jobs because she is unable to show up on time in the morning. She claims she
doesn’t have a problem because it only takes her 5 beers to get drunk—the same
amount as when she started drinking 5 years ago. She now spends most of her day
doing odd jobs so that she can afford to go out drinking. Her doctor told her that
her liver is suffering, but she continues to drink. What is her likely diagnosis?
She meets criteria for substance dependence, despite her lack of tolerance. She spends
most of her time involved in substance-seeking behavior, has had occupational
impairment, and has had a physical impact from use as well. She cannot be
diagnosed with substance abuse as dependence takes precedence.
A 19-year-old college student is brought to the ER by his fraternity brothers at 3 AM
after a Friday night party. The young man is arousable to painful stimuli only. His
pupils are only 1 mm, but reactive. You notice his respiratory rate is quite low. His
friends say there has been a lot of drinking at the party as well as some pills.
What drugs has the patient most likely ingested?
Alcohol and opiates (note pinpoint pupils)
What drug should be administered immediately after this patient arrives in the ER?
Naloxone
CHAPTER 20
Eating Disorders
What are the two major eating disorders
according to the DMV-IV-TR?
1. Anorexia Nervosa
2. Bulimia Nervosa
What are the two subtypes of Anorexia
Nervosa?
1. Restricting type
2. Binge-Eating/Purging type
What distinguishes the subtypes?
The presence of either regular binge
eating or purging behavior is Bingeeating/purging type. The absence of
either is restricting type.
What is the biggest distinguishing
characteristic between Anorexia
and Bulimia?
In anorexia there is a refusal to maintain
a body weight above 85% of ideal.
Bulimic patients may be of normal
weight.
criteria for anorexia nervosa?
All of the following:
Severe weight loss (weighs <85% of
ideal body weight)
Intense fear of gaining weight
Amenorrhea
Disturbed perception of body weight, or
denial of seriousness of weight loss, or
undue influence of weight on selfevaluation
What are the associated physical
or biological findings in anorexia
nervosa?
Lanugo
How is amenorrhea defined?
Absence of a menstrual period for at
least three cycles
Melanosis coli (in those that use laxatives)
Anemia
Leukopenia
Electrolyte imbalance
153
What is lanugo?
Fine, downy body hair, especially seen
on the trunk
What is melanosis coli?
Blackened areas on the colon, seen with
laxative abuse
What is a long-term risk of anorexia?
Osteopenia, Mitral Valve Prolapse,
Amenorrhea, Electrolyte Disturbance,
and Death
What are some of the warning signs
of anorexia?
Excessive dieting, exercise, use of
laxatives/diuretics/enemas
Abnormal eating habits
Body image disorder/body dysmorphic
disorder
Fear of becoming fat
Decreased libido
What is the typical profile of a patient
with anorexia?
Anorexia is most commonly seen in
adolescent to young adult females
who are very high achieving (either
academically, athletically, or both).
There is often a lot of conflict within
the family, sometimes described as a
controlling or overly protective mother.
Do patients with anorexia typically
have coexisting disorders?
Anxiety disorders are commonly seen,
as are mood disorders and substance
abuse.
What is the best treatment for anorexia
nervosa?
Nutritional therapy and psychotherapy
including cognitive-behavioral therapy
(CBT) can be helpful. Pharmacotherapy is
not terribly helpful.
criteria for bulimia nervosa?
All of the following:
Recurrent binge eating, with both a
large amount of food and a lack of
control during the episode
Compensatory behavior to prevent
weight gain (vomiting, laxatives,
exercise, etc)
Binge and purge behaviors occur at
least twice a week for 3 months
Self-evaluation influenced by body
shape and weight
Does not qualify for anorexia nervosa
diagnosis
Eating Disorders 155
What are common associated findings
in persons with bulimia nervosa?
Erosion of tooth enamel
Parotitis (inflammation of parotid
gland)
Calluses on the dorsal surface of the
hands
Electrolyte imbalance
Often normal body weight (may be
slightly overweight)
What is the cause of erosion of the
tooth enamel?
Repeated exposure to gastric acid
secondary to induced vomiting
What is parotiditis?
Swelling or infection of the parotid
glands, usually secondary to
vomiting
What causes the development of
calluses on the back of the hands?
Scraping fingers along teeth while
inducing vomiting
What common medical consequences
are seen with repeated vomiting?
Hypokalemia
Metabolic Alkalosis
Endocrine disturbances
Growth disturbance
Bradycardia and dysrhythmias
What is a traumatic consequence
of the repeated induced vomiting
seen in bulimia nervosa?
Esophageal varices and/or Mallory-Weiss
tears from repeated retching
How can purging be accomplished?
Induced vomiting
Laxative/diuretic/enema use
Excessive exercise
Do Bulimics have to vomit or use
laxatives to meet criteria?
No. Even excessive exercise can
be a “purging” behavior.
What are some of the psychosocial
features of patients with bulimia?
Poor self-image
Depression and other mood disorders
What is the best treatment for bulimia
nervosa?
Psychotherapy
Behavior therapy
Antidepressants—selective serotonin
reuptake inhibitors (SSRIs) preferred
Nutrition education
Regular meals
Healthy exercise
What is Eating Disorder Not Otherwise
Specified (NOS)?
A grab-bag of disordered eating that
does not meet criteria for Anorexia or
Bulimia. This includes:
• Purging behavior without true binge
eating
• Anorexia criteria without amenorrhea
• Restricting type anorexia without
significant weight loss (ie, no binge
eating/purging to meet bulimia
criteria)
• Bulimia criteria except at a lower
frequency than required for
diagnosis
• Chewing and spitting out large
amounts of food
• Binge eating without purging
behavior
CLINICAL VIGNETTES
A 17-year-old woman comes to your office complaining of fatigue. Upon careful
examination you see erosion of the enamel on her molars. You check an electrolyte
panel and find her to be hypokalemic.
What are the possible psychiatric disorders that may be present?
This patient may have anorexia nervosa, bulimia nervosa, or eating disorder NOS.
How do you distinguish anorexia nervosa and bulimia nervosa?
To distinguish these disorders you would need to know her body weight vs her
ideal body weight.
What is the likely cause of her hypokalemia? If you took an arterial blood gas,
what would you expect the pH to be?
Her hypokalemia is likely due to recurrent vomiting—this will also cause a
+
metabolic alkalosis (think loss of stomach H ), so you would expect her pH to be
high (alkalemic).
Eating Disorders 157
A 12-year-old male comes into your office asking for help in losing weight to make
the wrestling team. He states that he has been exercising significantly to lose
weight, but with no effect. He is terribly afraid of gaining weight, believes he is
horribly fat, and hates himself for weighing so much. His ideal body weight is 100 lb
and he currently weighs 90 lb. He states he’d like to weigh 80 lb and requests you
to give him diuretics to help him do so, which you refuse to do.
What is his current likely diagnosis?
His current diagnosis is Eating Disorder NOS—he would meet criteria for anorexia
nervosa, but he does not weigh <85% of ideal body weight.
If the patient began to use diuretics against your advice and lost 10 lb, would it
change?
If he began to use diuretics and went down to 80% of his ideal body weight, he
would qualify for a diagnosis of Anorexia Nervosa, Binge-eating/purging type
(note that he does not need to binge eat to qualify; purging alone is enough).
What if he started binge eating as well as using diuretics and still weighed 90 lb?
If he is both binging and purging but does not weigh under 85% of his ideal body
weight, he would qualify for a diagnosis of Bulimia Nervosa.
CHAPTER 21
Child Psychiatry
PERVASIVE DEVELOPMENT DISORDERS
of the pervasive development
disorders?
Failure to acquire or early loss of
communication and social interaction
skills
What are the pervasive development
disorders?
Autistic disorder
Asperger disorder
Rett disorder
Childhood disintegrative disorder
significant communication problems,
difficulty in forming social
relationships, repetitive behavior,
and unusual abilities?
Autistic disorder
What term describes the unusual
abilities (eg, memory, calculation skills)
that some autistic patients have?
Savant
The onset of autistic disorder must be
before what age?
3 years of age
What is the risk of autism in
monozygotic twins and siblings?
Increased risk due to genetic component
The incidence of autistic disorder is
increased in which conditions?
Congenital anomalies
Perinatal complications
Congenital rubella
Phenylketonuria
Fragile X syndrome
Tuberous sclerosis
What has been shown in multiple
analysis not to be associated with autism?
Vaccination
159
Which brain abnormalities are
associated with autism?
Seizures
Electroencephalogram (EEG)
abnormalities
Anatomic and functional
abnormalities
Which gender is most likely to be
affected by autism?
Males; Four times more likely
Which gender is more severely
affected with mental retardation
in autism?
Females
How is autistic disorder treated?
Therapy aimed at increasing
communication, social, and self-care
skills
What is the IQ of many autistic patients? Generally low; may have normal
nonverbal IQ
Which disorder is a milder form
of autism?
Asperger disorder
What are the primary deficits in a
patient with Asperger?
Problems forming social relationships
Repetitive behavior
Acute interest in obscure topics
Which areas of functioning are normal
in Asperger but are usually deficient
in autistic patients?
Cognitive and verbal skills
Which disorder is characterized by a
decrease in social, verbal, and cognitive
development after a period of normal
functioning?
Rett disorder
of Rett disorder?
Stereotyped hand-wringing movements
Poor coordination
Impaired language development
Loss of hand skills
Loss of social engagement
Deceleration of head growth
Which gender is primarily affected
by Rett disorder?
Females
What is the genetic inheritance of
Rett disorder?
X-linked
Child Psychiatry 161
What happens to males affected
by Rett disorder?
They die before birth.
Which rare disorder is characterized
by a diminution of cognitive, motor,
social, and verbal development after
2 to 10 years of normal functioning?
Which gender has the highest
incidence of childhood
disintegrative disorder?
Boys
DISRUPTIVE BEHAVIOR DISORDERS
of disruptive behavior disorders?
Improper behavior; problems with
school performance and social
relationships
Which disorders are classified
as disruptive behavior disorders?
Conduct disorder
Oppositional defiant disorder
insistent behavior that violates
social norms, deviation from societal
and parental rules, property destruction,
and aggressive behavior?
Conduct disorder
What are examples of the behaviors
that violate social norms that are
common in patients with conduct
disorder?
Arson
Theft
If a person is 18 years or older and
still exhibits the symptoms of
conduct disorder, which disorder
might they have?
Antisocial personality disorder
persistent disobedient, defiant,
and negative behavior toward
figures in authority?
Oppositional defiant disorder
What are the primary treatment
modalities for the disruptive
behavior disorders?
Psychotherapy and a Structured
environment, sometimes
pharmacotherapy
Animal harm
Assault
ATTENTION-DEFICIT HYPERACTIVITY DISORDER
of attention-deficit hyperactivity
disorder (ADHD)?
Inattention
Hyperactivity
Impulsivity
Impairment in multiple settings
(eg, both school and home)
Which gender is most likely to be
affected by ADHD?
Boys
By definition, ADHD symptoms
must be evident by which age to be
given the classification of ADHD?
Before 7 years of age
How long must the symptoms of ADHD
be present to be given the classification
of ADHD?
At least 6 months
What percentage of the general child
population in the United States is
affected by ADHD?
3% to 7%
What is the intelligence level of persons
with ADHD?
Normal intelligence
What percentage of ADHD patients
have symptoms that persist into
adulthood?
20%
What are the primary treatment
modalities of ADHD?
Stimulants—usually amphetamines
What is a non-stimulant medication
for individuals with ADHD greater
than the age of 6?
Atomoxetine
Which single drug is most widely
prescribed for ADHD?
Methylphenidate
OTHER NEUROPSYCHIATRIC DISORDERS OF CHILDHOOD
chronic motor and vocal tics and
involuntary use of profanity?
Tourette syndrome
Child Psychiatry 163
In which age group is Tourette
syndrome most likely to be
diagnosed?
Usually 7 to 8 years of age; onset
usually by 21 years of age
Tourette syndrome has a high
comorbidity with which other
psychiatric disorders?
ADHD
Obsessive-compulsive disorder
What is the primary treatment
for Tourette syndrome?
Dopamine-blocking antipsychotics
(if interfering with social interactions)
What is a treatment for Tourette
syndrome that is refractory
to medications?
Botox (for tics) or Deep brain stimulation
excessive and inappropriate anxiety
concerning separation from parents,
caretakers, and their home and
production of physical complaints
to avoid going to school?
Separation anxiety disorder
What is the most common age of
onset in a person who presents
with separation anxiety disorder?
7 to 8 years of age
Which treatment modalities are most
effective in the treatment of separation
anxiety disorder?
Psychotherapy, especially cognitivebehavioral therapy
a refusal to verbally communicate
in some or all social situations in
which the child may communicate
with gestures?
Selective mutism
In which gender is selective mutism
more common?
Girls
Selective mutism has a poor
prognosis if it persists after
which age?
10 years of age
What is the primary trigger for the onset
of separation anxiety disorder and
selective mutism?
Stressful life events
What is the most common treatment
modality for selective mutism?
Family and behavioral therapy
CLINICAL VIGNETTES
A distressed mother comes to your clinic with her 4-year-old daughter. She claims
her daughter was completely normal up until last year when she had a regression
of her social and cognitive skills—right after her last batch of immunizations. The
mother is now considering suing the vaccine manufacturer for causing her child to
have autism. What can you tell the mother is the most likely diagnosis of the child?
A father brings his 9-year-old son in to evaluate him for ADHD. His teacher told
the father that his son is impulsive, inattentive, and can’t stay in his seat. The
father says that neither he nor his mother has noticed these symptoms anywhere
else, but he believes the teacher. He asks if his son should be started on
medication. What should you advise the father?
The child shouldn’t be started on any medications at this time. The child’s
behavior is limited only to the school setting and does not meet criteria for ADHD.
A 14-year-old male is brought to a psychiatrist because of his disregard for rules
set by authority figures at home and in school. He has set numerous fires in his
neighborhood. His parents are concerned that he seems to have no regard for the
feelings of others. Which disorder is this patient most likely to be diagnosed with?
Conduct disorder
A 3-year-old girl presents with problems forming social relationships. She engages
in repetitive behavior, and she has a strong interest in learning all about the
different types of bubble gum in the world. Her mother states that the girl has not
had any cognitive deficits and has had no developmental language delay. Which
condition is the patient most likely to be diagnosed with?
Asperger disorder
CHAPTER 22
Psychopharmacology
What is the only property of
benzodiazepines to which
tolerance does not develop?
Tolerance does not develop to the
antianxiety/anxiolytic effects of benzos;
tolerance may develop to the hypnotic,
muscle relaxant, and anticonvulsant
effects (eg, benzodiazepines should not
be used for long-term seizure control).
Which benzodiazepines are considered
anxiolytics?
Alprazolam
Chlordiazepoxide
Clonazepam
Clorazepate
Diazepam
Lorazepam
hypnotics (used to facilitate sleep)?
Quazepam
Midazolam
Estazolam
Flurazepam
Temazepam
Triazolam
What drug can be used to reverse
the effects of benzodiazepines?
Flumazenil (Romazicon)—though it is
used with caution as it can precipitate
withdrawal seizures
What is the general mechanism
of action of benzodiazepines?
Benzodiazepines target the GABAA
(γ-aminobutyric acid A) chloride channel
receptor, resulting in an increase in the
receptor’s affinity for and causing the
ion channels to open more frequently, thus
allowing more chloride ions to pass
through.
Is there a danger in taking
benzodiazepines during pregnancy?
Benzodiazepines can cross the placenta,
and therefore should not be taken
during pregnancy if possible.
They are categories D and X.
165
How many phases are there in
benzodiazepine metabolism?
There are three phases.
1. Phase 1: The R1 and R2 residues are
oxidized.
2. Phase 2: The R3 residue is
hydroxylated.
3. Phase 3: The hydroxyl compounds
are conjugated with glucuronic acid.
Where does benzodiazepine
metabolism occur?
In the liver
Which benzodiazepines skip phase 1
and/or phase 2 of metabolism and are
therefore safer to give to patients
with liver failure?
Desmethyldiazepam
What are the symptoms of
benzodiazepine withdrawal?
Anxiety
Insomnia
Irritability
Delirium, Psychosis
Weakness
Oxazepam
Temazepam
Lorazepam
Midazolam
Triazolam
Tremor
Seizures
What are the possible side effects
of benzodiazepines?
Drowsiness
Confusion
Motor incoordination
Cognitive impairment
Anterograde amnesia
to be high potency?
Triazolam
Alprazolam
Clonazepam
to be low potency?
Diazepam
Chlordiazepoxide
Oxazepam
Which benzodiazepines are most
commonly used for treatment
of alcohol withdrawal seizures
(delirium tremens)?
Chlordiazepoxide
Lorazepam
Diazepam
Psychopharmacology 167
Which benzodiazepines are indicated
Diazepam and lorazepam
for treatment of status epilepticus,
as they can be given intravenously (IV)?
Why are benzodiazepines safer
pharmacologic agents to use to
treat anxiety than barbiturates?
Less potential for abuse
Higher therapeutic index
of barbiturates?
Barbiturates target the GABAA chloride
channel receptor and its action on
chloride entry into the cell, which
results in membrane hyperpolarization.
There is an increase in the duration of
the chloride channel opening and a
decrease in neuron excitability.
What is the mechanism of action and
common use of Buspirone?
It is a 5-hydroxytryptamine receptor 1A
(5-HT1A) (serotonin) agonist that may be
used to treat anxiety, particularly useful
in those for whom benzodiazepine
therapy is contraindicated (the elderly
and those with a history of substance
abuse).
Which short-acting antianxiety agent
is used to treat insomnia?
Zolpidem tartrate
What is the most commonly prescribed
class of drugs for the treatment
of depression?
SSRIs (selective serotonin reuptake
inhibitors)
of SSRIs?
They work by inhibiting neuronal
uptake of serotonin, thereby increasing
the synaptic concentration of serotonin.
What are the names of commonly
prescribed SSRIs?
Fluoxetine
Fluvoxamine
Paroxetine
Sertraline
Citaprolam
What serious side effects have a greater
incidence associated with the SSRI
Paroxetine?
Anticholinergic effects, sexual
dysfunction, and withdrawal syndrome
What caution should you take while
using SSRIs in children and adolescents?
There is a black box warning about
increased suicidal thoughts in patients
<25 years—warn your patients and
monitor carefully.
Which SSRIs are now available
in generic form (and may be a better
choice for patients with a limited
budget)?
Fluoxetine (Prozac)
Paroxetine
Sertraline
Citalopram
Why does fluoxetine and paroxetine
have a greater association with drug
interactions than other SSRIs?
They have greater P-450 inhibition than
the other SSRIs.
Why is insomnia a troubling side effect
of fluoxetine?
It causes the most central nervous
system (CNS) activation of the
SSRIs.
Which SSRI is most likely to cause
gastrointestinal disturbances?
Sertraline (Zoloft)
Which SSRI is currently only
indicated for obsessive-compulsive
disorder?
Fluvoxamine
of bupropion (Wellbutrin)?
It is thought to work mostly on dopamine
and norepinephrine, though the exact
mechanism is unknown.
What is the major indication
for bupropion?
What is another common indication
for bupropion?
Smoking cessation
What is a unique side effect
of bupropion that should be thought
of before prescribing it in epileptic
patients?
It can lower the seizure threshold,
especially in quick release formulas
and at high doses.
What is a common indication for the use
of trazodone?
Insomnia
What is a problematic side effect of the
antidepressant trazodone seen mostly
in males?
Priapism (painful, persistent erection)
of tricyclic antidepressants (TCA)?
Tricyclic antidepressants inhibit the
neuronal reuptake of both serotonin
and norepinephrine, thus, increasing
the availability of serotonin and
norepinephrine at the synaptic
cleft.
prescribed tricyclic antidepressants?
Amitriptyline
Clomipramine
Doxepin
Desipramine
Imipramine
Nortriptyline
Why are tricyclics used less often
than SSRIs?
Side effects and potential for lethal
overdose. They are still very efficacious
medicines.
What other syndrome are TCAs
indicated for treating?
Chronic and neuropathic pain
What are common side effects
of tricyclic antidepressants?
Tricyclic antidepressants have
anticholinergic effects including dry
mouth, blurry vision, constipation,
urinary retention, confusion, and
memory deficits.
What are the effects of TCA overdose?
Cardiac effects are the most
dangerous—notably widened QRS,
prolonged PR and QT intervals.
Sedation, delirium, and anticholinergic
effects may also be present.
What is the most important clinical
test in evaluating suspected tricyclic
overdose?
ECG
What is the treatment of acute tricyclic
overdose?
IV Sodium Bicarbonate
Which tricyclic antidepressants
are known to have more anticholinergic
effects?
Tertiary tricyclics (eg, amitriptyline)
What are examples of other tertiary
tricyclics antidepressants?
Imipramine
Which tricyclic agent is the least
sedating?
Desipramine
Which tricyclic is prescribed for
enuresis (bed-wetting)?
Imipramine
Which tricyclic is classically prescribed
for obsessive-compulsive disorder?
Clomipramine
Note: This is the most serotonin-specific
tricyclic.
Doxepin
Which tricyclic is the least likely
to cause orthostatic hypertension?
Nortriptyline
What is the most common indication
for MAOIs (monoamine oxidase
inhibitors)?
Treatment of atypical depression
(depression with increased sleep,
appetite, and leaden paralysis)
of MAOIs?
They work by inhibiting the
mitochondrial enzyme monoamine
oxidase which metabolizes
norepinephrine, serotonin, and
dopamine, resulting in a buildup
of these biogenic amines and their
subsequent leakage into the
synapse.
prescribed MAOIs?
Selegiline
Phenelzine
Tranylcypromine
What are the common side effects
of MAOIs
Sedation
Anticholinergic effects
Orthostatic hypotension
Cardiac conduction disturbances
What other medication must be avoided
in patients taking MAOIs?
Stimulants and pseudoephedrine must
be avoided because they can cause
What other substance must be avoided
by patients taking MAOIs?
Tyramine, which is found in aged
cheeses, beer, certain meats and fish,
fava beans, red wine (particularly
Chianti), avocados, chocolate,
and dairy products. Signs of
tyramine ingestions include
headache, arrhythmias, and
What MAO inhibitor is now available
in a transdermal patch which does not
require a change in diet?
Selegiline, which is also useful for
patients who cannot swallow oral
medicines
What are some pharmacologic agents
that can cause psychosis?
Amphetamines
Cocaine
L-Dopa
What is the mechanism of action for
most typical antipsychotics?
They are dopamine receptor
antagonists.
What is the most popular of the
biochemical theories that explain
the development of psychosis?
The dopamine hypothesis which cites
an increase in dopamine transmission
as the cause. This is supported by the
clinical potentcy of typical
antipsychotics being directly related
to their affinity to the D2 receptor.
What is the most common problematic
side effect of typical antipsychotics?
Extrapyramidal effects/Parkinson-like
side effects:
Bradykinesia
Rigidity
Tremor
Acute dystonia
Akathisia
Note: Chronic tardive dyskinesias may
also occur.
Which of the extrapyramidal side
effects is a flag for caution for future
use of typical antipsychotics?
Acute dystonic reaction
Which typical antipsychotics have the
most extrapyramidal effects?
Fluphenazine = haloperidol
> chlorpromazine > thioridazine
Note: This is correlated with
potency/D2 blockade.
Which is the most potent of the typical
antipsychotics?
Fluphenazine
What pharmacologic evidence does not
support the dopamine hypothesis?
Atypical antipsychotics are very
efficacious, but many work on other
neurotransmitters and have little effect
on dopamine.
What is the mechanism of action of the
atypical antipsychotic clozapine?
It acts on dopamine, serotonin,
and acetylcholine receptors.
What is the greatest benefit of atypical
antipsychotics?
They usually have fewer extrapyramidal
side effects than typical antipsychotics.
What is the major side effect to beware
of with clozapine?
Agranulocytosis → necessitates weekly
or biweekly white blood cells (WBC)
monitoring in patients on clozapine
therapy.
What is the biggest benefit of clozapine?
It is efficacious for treatment. It is
efficacious for resistant schizophrenia,
though because of the side effects and
monitoring it is never first line.
What is the mechanism of action of the
atypical antipsychotic risperidone?
It works by blocking both dopamine
and serotonin receptors.
What are other side effects of
antipsychotic therapy?
Weight gain and metabolic syndrome
Anticholinergic effects
Antihistaminergic effects/sedation
Amenorrhea
Temperature dysregulation
Neuroleptic malignant syndrome
Blood dyscrasias
Sexual dysfunction
What is the cause of amenorrhea
in women taking antipsychotics?
Dopamine receptor antagonism leading
to elevated prolactin levels
Which pharmacologic agents are used
to treat acute mania associated with
bipolar disorder?
Lithium
Atypical antipsychotics
Valproic Acid (aka Depakote, valproate)
Carbamazepine
Benzodiazepines
What agents are used for maintenance
therapy in bipolar disorder?
Lithium
Valproic acid
Carbamazepine
Atypical antipsychotics
Lamotrigine (Lamictal)
What are some of the side effects
of lithium?
Polyuria → acts as an antidiuretic
hormone (ADH) antagonist to cause
nephrogenic diabetes insipidus
Tremor
Hypothyroidism
Weight gain
Gastrointestinal effects (nausea,
vomiting, diarrhea)
Leukocytosis (high white blood
cell count)
Acne
Note: Use of lithium requires close
monitoring of serum levels.
Which pharmacologic treatment is safe
in pregnant bipolar women?
None. Risk of relapse must be weighed
against the risks of birth defects.
Electroconvulsive therapy is likely the
safest treatment overall in pregnancy.
What is the main drawback of using
antipsychotics such as olanzapine
for bipolar maintenance?
Side effects, especially weight gain
Which anticonvulsants are used to
treat bipolar disorder?
Carbamazepine
Valproic acid
Lamotrigine
What type of therapy is used for major
depressive order that is refractory
to treatment?
Electroconvulsive therapy (ECT)
In what other psychiatric conditions
can ECT be used as treatment therapy?
Acute mania
When does the maximum response
to ECT usually occur?
After a period of several weeks
over which 5 to 12 treatments are
administered.
What is the biggest side effect of ECT?
Memory loss (Retrograde amnesia),
which may or may not be permanent.
How can the amnesia and memory
loss associated with ECT be
minimized?
Unilateral electrode placement
Is modern ECT different than
20 years ago?
Absolutely. Use of appropriate
anesthesia and modern ECT techniques
has significantly reduced side effects
and complications.
All possibilities considered,
what is the most efficacious
treatment for depression?
ECT
Schizophrenia with catatonic symptoms
Depression, particularly with psychotic
symptoms or in pregnancy
Catatonia
CLINICAL VIGNETTES
An unresponsive young woman is brought to the ER by her college roommate.
Her roommate states that she had confided in her that she was being treated for
depression for quite some time with little success. She found an empty pill bottle
by the patient as well, but didn’t bring it in. On examination the patient has
widely dilated pupils, a dry mouth, and tachycardia.
What was likely in that bottle of pills taken by the patient?
She likely is suffering from tricyclic antidepressant overdose. Note the anticholinergic
symptoms and the limited success of treatment (perhaps necessitating a few different
medication trials).
What diagnostic test would you order? What result do you expect on that test?
You should order an ECG, on which you would likely see a prolonged PR interval,
a widened QRS, and a long QT interval.
What is the appropriate management of the patient?
Of course you would start with ABCs, but intravenous bicarbonate is a specific
treatment for TCA overdose.
A 62-year-old patient with schizophrenia comes in to inquire about new treatment
options. He has been on haloperidol which has controlled his symptoms well. His
past medical history includes pre-diabetes, obesity (though he’s trying to lose
weight), hypertension, and a family history of coronary artery disease. He says that
he has heard that some of the new atypical antipsychotics are more effective than
his old agent.
What should you advise him?
Atypical medications are no more effective than typical agents, with the notable
exception of clozapine. The main advantage of atypical agents is a more favorable
side-effect profile with less EPS and tardive dyskinesia than typical agents.
What side-effects might you worry about in this patient?
Prominent metabolic effects and weight gain are side effects of atypical agents,
which would be especially detrimental to this patient.
If he was treatment resistant, would this change your thinking?
Patients who have failed multiple other antipsychotic medications may benefit
from clozapine—though the risk of agranulocytosis and subsequent FDAmandated laboratory monitoring limit its widespread use.
SECTION III
Ethics, Health Care,
and Statistics
CHAPTER 23
Clinical Practice and
Difficult Situations
The USMLE sometimes gives “quote” questions asking you to pick something to
say in a provider-patient interaction. In general, it’s usually a good idea to get more
information, respect the patient’s autonomy, keep information confidential, and
never lie.
What is the importance of rapport?
The relationship and trust built between
the doctor and patient greatly enhance
the effectiveness of care.
What are the most important
things to do if a medical error
is committed?
Admit the mistake and apologize for it.
Never try to cover up an error.
What should you do if a patient tries
to give you a gift?
You should thank the patient for their
thoughtfulness, but not accept it. Gift
giving may be misinterpreted as
“buying better care”—equal care should
be given to all.
When is it appropriate to refer a patient
to another physician?
Only when the problem cannot be
handled by yourself. This is rarely the
answer on the USMLE—it is
inappropriate to refer a patient to a
psychiatrist just because they have a
difficult situation to be dealt with!
What would you say to a patient with
a terminal illness who wants to die?
Get more information about why they
feel this way. Commonly, they are
afraid of dying in pain; they may
have seen a loved one die painfully.
Reassure them that you will stick with
them and that their symptoms will
be well controlled. Also assess for
untreated depression.
177
Your fellow resident gets called in to
work at night and you smell alcohol
on his breath. He says he only had two
beers and asks you not to say anything.
Do you tell someone?
Yes. It’s unethical to endanger patient
care with a possibly impaired physician.
A patient’s sibling asks you for
information about their condition—
do you give it to them?
No. You must have formal permission
from the patient to share their health
information with anyone other than
them.
Can you tell information about a
patient to someone uninvolved in
their care?
No. This is a violation of the Health
Insurance Portability and Accountability
Act (HIPPA). You should be careful
where and with whom you discuss
any patient information.
You see a former patient at a bar,
whom you treated briefly 10 years ago.
Can you ask them out on a date now?
No. It is never ethical to have a
romantic relationship with a patient,
former or current.
When is it OK to withhold information
about an illness from a patient?
If the patient tells you they don’t want
to know. It must be the patient that
indicates this—not a family member.
A patient asks you to do a procedure
that is legal, but is against your belief
system. Must you do it?
No, you do not need to do anything nor
treat anyone that would compromise
your beliefs. However, you should refer
the patient to someone who will treat
them, as well as provide support in the
meantime.
What is a good general approach to an
emotional patient—be it angry, sad,
or scared?
Label and validate their emotions, then
offer support. Eg: “You sound like you
are scared—I don’t blame you, it’s OK
to be scared about this procedure.”
What if the patient starts to cry?
Let them cry. Try to be comfortable with
silence when appropriate. Offering a
tissue is always a good gesture.
What are the steps to giving bad news?
1. Set the stage—find a private place
and ensure you have a proper
amount of time free.
2. Find out what the patient knows
about his/her illness.
3. Find out how much the patient
wants to know.
4. Tell the information.
5. Respond to feelings.
6. Make a plan for next steps.
Clinical Practice and Difficult Situations 179
Which of the steps above is most likely
to be asked on the USMLE?
Finding out how much the patient
knows about their illness (no 2). It’s
always good to get information first so
you can frame the discussion.
How do you use an interpreter?
Speak to the patient, not the interpreter.
Speak clearly, being sure to pause
intermittently to allow the interpreter
to convey information to the patient.
Is it OK to allow a child or family
member to act as an interpreter?
No, not if it can be helped. Even if the
family member is fluent, it is good to at
least offer to get an interpreter for the
patient. Family members may also have
their own agenda that may unduly
influence the patient.
What is patient adherence (formerly
called “compliance”)?
The degree to which the patient follows
the advice of the treating physician
What are barriers to patient adherence?
Complicated medical regimens
Poor physician-patient rapport
Lack of patient involvement in the
treatment plan
Infrequent appointments
Poor support structure/inadequate help
at home
How might a physician make a
treatment plan less complicated?
The treatment plan can be simplified by
limiting:
• The number of medications the
patient is taking
• The number of times the medications
is taken per day
• The number of changes made at each
visit
What is an open-ended question?
A question that is intentionally left
broad, such that the patient can say
what is really on their mind—“What
brings you into the clinic today?” or
“Tell me about your stomach pain.”
What is a close-ended question?
A very specific question with a discrete
answer. Used to get more detail—
“Did you have nausea?” “How
frequently do you have pain?”
This is also useful with seductive
or disorganized patients.
What is the cone method of
interviewing, or “coning”?
Starting with an open-ended question,
then progressively narrowing down to
more specific close-ended questions.
CLINICAL VIGNETTES
A 79-year-old woman came into the hospital complaining of shortness of breath.
After an extensive workup, you find that she has metastatic lung cancer. Her son
finds you in the hallway and states “In our culture our elders do not like to know
about serious illnesses. It is my duty as a son to take care of my mother.” You are
unclear about what cultural practices are appropriate to the patient. How do you
approach this situation?
It may very well be that there is a cultural aspect to discussions of terminal illness
that is appropriate to consider in this case. If available in your institution, a “cultural
consult” may be appropriate with someone more versed than you in these issues. If
not, it would be inappropriate to withhold information based solely on what the son
of the patient says. The best case would be to sit down with the patient and ask her
about her cultural beliefs around illness—“Some members of your culture prefer
not to talk about their illnesses, but instead allow their children to make medical
decisions for them. How do you feel about the discussion of illness?”
A patient with known sickle cell disease comes into the ER. He states he is in 10/10
pain and requests 15 mg of morphine. The nurse says he is a “frequent flier” and
worries that he is an addict. He doesn’t look like he’s is in any pain. What should
you do?
Treat his pain. With known disease it is more important that he does not suffer
than to distinguish his symptoms from malingering. Remember, sickle cell crisis
can be extremely painful even without outward signs of pain.
You call a family meeting for a chronically ill patient whom you just found out has
leukemia. Everyone is comfortably sitting in your office. What do you say next?
“What do you know about your illness?” It is important to be open-ended and see
what the patient’s thoughts are. Most likely he has been thinking about this much
more than you and probably is very well informed; or he may have completely
unrealistic views that would be good to learn about before the conversation. Probe
a bit to understand this, and then to ascertain how much he wants to know before
delivering the news.
CHAPTER 24
Medical Ethics and
Legal Issues
What are the four principles
of medical ethics?
1.
2.
3.
4.
What is Autonomy?
The patient has the right to make their
own decisions regarding their care.
What is Beneficence?
The principle that physicians should be
of benefit to their patients.
What is Nonmaleficence?
Do no harm.
What is Justice?
The allocation of resources in a fair and
just manner, including equal treatment.
Of these principles, which one tends
to take precedence in ethical questions,
especially on the USMLE?
Patient Autonomy
What is the principle of double-effect?
When an action that has a primarily
good effect may also cause an
unintended bad effect, but is still
permissible.
What is the classic example of
double-effect?
Giving morphine to relieve the pain of a
dying patient, even if it causes respiratory
depression hastening the patient’s
death. As long as the primary intent
of the treatment is to reduce pain and
not to kill the patient, it is ethically
permissible so long as there is pain
to be relieved.
Is malpractice a crime?
No—malpractice is a civil court matter.
181
Patient Autonomy
Beneficence
Nonmaleficence
Justice
What four elements in a malpractice
case must exist in order to find liability
with the treating physician (otherwise
referred to as the 4 D’s)?
Duty: There must be an established
doctor-patient relationship.
Deviation or dereliction: Treatment
strayed from established standard of care.
Damages: Physical, psychological, or
social damage was done.
Direct cause: Damages were caused
directly by negligence or dereliction.
How is a deviation from standard
of care decided upon?
A jury decides if there has been a
deviation from the standard of care.
The jury makes this determination based
upon testimony of one or more expert
witnesses who testify as to the standard
of care as generally recognized by the
medical community and how the
defendant deviated from that standard
of care.
What is the best way to avoid
a malpractice suit?
If an error is made, admit when you are
wrong and apologize to the patient.
Maintain a healthy physician-patient
relationship.
Keep current with standards of care.
When can a physician become impaired? When clinical judgment is affected by
the following:
• Physical illness
• Mental illness
• Substance abuse
Is it acceptable to work with an
impaired health-care provider?
No. It is the ethical duty of a physician
to report an impaired health-care
provider to the proper authorities.
How does a physician’s human
immunodeficiency virus (HIV) status
affect his or her ability to practice
medicine?
Under the American Medical Association
(AMA) ethical guidelines, an HIV
physician should not engage in any
activity that would put a patient at risk
of contracting HIV (eg, an HIV-positive
surgeon may be precluded from
practicing surgery. Some states require
that an HIV-positive physician disclose,
as part of the informed consent process,
his or her HIV status before engaging in
an invasive procedure that would put
the patient at risk).
Medical Ethics and Legal Issues 183
Is it acceptable for a physician to
establish a romantic relationship
with a patient or former
patient?
No—it’s not acceptable under any
circumstances.
What is competence?
Competence is the ability to evaluate
situations and make sound judgments
that are:
• Consistent throughout time
• Consistent with the patient’s belief
system (unless the belief system is
delusional)
Who is considered legally competent?
All adults >18 years of age and
emancipated minors—including
adults with mental illness or mental
retardation—unless declared
incompetent by a court of law
Who is an emancipated minor?
Someone <18 years of age who is:
• Financially independent of his or her
parents
• Married
• Serves in the armed forces
Can a person be competent in some
areas and not others?
Yes. Legal competence is situation
specific (eg, competence to stand trial)
and can change with time. A patient
can be legally competent, but not
medically competent if he or she lacks
the capacity to make, understand, or
communicate his or her health-care
decisions.
Can a physician deem a patient
incompetent?
No. Legal incompetence is determined
in a court of law. Any physician (not
just a psychiatrist) can determine if a
patient has the capacity to make
medical decisions.
If a patient is ruled incompetent, how
does the patient become competent
again?
The case must be brought before the
judge again, and after reviewing the
medical evidence, the judge determines
whether the patient has regained legal
competence.
Who may give informed consent
for a patient?
The patient only unless:
• It is an emergency, delay puts the
patient’s life at risk, and there is no
one available to give consent on the
patient’s behalf.
• The patient is legally incompetent
(depending upon state law, the
legally appointed guardian, or the
agent named in a durable power of
attorney for health care gives
consent).
• The patient lacks the capacity to
make, understand, or communicate
his or her health-care decisions (a
surrogate decision-maker gives
consent as provided by state law,
usually in the following order of
priority: health-care agent, spouse, an
adult child, parent, an adult sibling,
or a grandparent).
• The patient is a nonemancipated
minor (parent or legal guardian gives
consent, and in some states, someone
standing in the place of a parent may
also give consent).
What happens if a patient lacks
the capacity to make, understand, or
communicate his or her health-care
decisions and has not named a healthcare agent under a durable power
of attorney for health care or been
appointed a legal guardian by
the court?
A surrogate decision-maker may give
consent on the patient’s behalf and
should make a good-faith effort to make
decisions based upon what the patient
would have chosen. State law designates
a list of surrogate decision-makers,
usually in the following order of priority
(in the absence of a health-care agent or
legal guardian): spouse, adult child,
parent, adult sibling, or a grandparent.
State laws may differ.
What is an advance directive?
A decision made by a patient about
what type of medical care he or she
wishes to receive in case that he or
she is not able to make decisions in the
future.
What is a durable power of attorney
for health care?
A durable power of attorney for health
care (or health-care proxy) is a legal
document that allows the patient to
designate a health-care agent to make
health-care decisions on behalf of the
patient when and if the patient is unable
to do so. It is an advance directive.
What is a living will?
A living will is a legal document that
allows a patient to decide, in advance,
whether he or she wants to be kept
alive by artificial means if two doctors
diagnose that the patient is (1) terminally
and incurably ill, (2) in a persistent
vegetative state, or (3) in an irreversible
coma. State laws may differ as to
conditions under which a living will
may be honored.
What is a DNR (do not resuscitate) order? A DNR order is an order written
by a physician, after determining
whether the patient is a candidate
for nonresuscitation and obtaining the
appropriate consent that directs medical
personnel not to resuscitate a patient in
the event of cardiopulmonary arrest.
Do DNR orders mean no interventions
are done on a patient?
No. Patients may choose to still have
antibiotics, fluids and nutrition, or other
“non-heroic” means depending on their
wishes.
When does a judge consent for medical
treatment of a minor?
When a parent or legal guardian refuses
to consent to medical treatment on the
minor’s behalf, and the physician
believes that the treatment is medically
necessary and justifies court intervention.
A court is more likely to intervene when
the proposed treatment carries a low
risk and high benefit or when the
minor’s life is threatened.
Does this apply to a fetus?
No. The competent pregnant mother, in
most circumstances, has a right to refuse
any intervention on the part of the fetus
even if it compromises her own or the
fetus’ life. In some states, courts have
intervened on behalf of a viable fetus.
Under what circumstances can a
nonemancipated minor receive
treatment without the consent
of his or her parent or legal guardian?
Although the answer is state dependent,
most states allow minors to consent for
treatment involving sexually transmitted
diseases (STDs), contraception and
pregnancy, and alcohol or illegal
substance use. Some states also allow
minors to consent for an abortion.
Other states allow a minor to consent
to an abortion, but require parental
notification or a court order waiving
parental notification.
When can a patient refuse treatment
even though refusal is life threatening?
Anytime, as long as they have the
capacity to refuse the treatment, and
the refusal is an informed refusal.
Does this include artificial
life support?
Yes
Is removing artificial life support the
same as physician-assisted suicide?
No. Removing artificial life support is a
decision that the competent, informed
patient is allowed to make. It does not
accelerate the natural course of the
patient’s disease process. Physicianassisted suicide is illegal in most states
because it purposely accelerates
death.
When can a physician decide to remove
life support without the consent of the
patient or patient’s decision-maker?
A physician may remove life support
without consent if the patient is legally
dead. The patient must be “brain dead”
in order to be declared legally dead in
the United States, which includes global
dysfunction of the brain (coma) and
absent brainstem reflexes.
Is palliative care of the terminal patient
the same as euthanasia?
No. Palliative care is not done with the
intention of accelerating death. It is
done with the intention of making the
patient comfortable through the natural
end point of a terminal illness. However,
palliative care may unintentionally
accelerate death as a side effect.
What is an informed consent?
Informed consent is required if the
proposed treatment or procedure
involves a material risk to the patient.
An informed consent includes the
voluntary agreement by a patient to
proceed with treatment after the
physician has discussed the procedure,
risks, benefits, and outcome of the
procedure or treatment, alternative
treatments (including no treatment),
and the risk, benefits, and outcomes
of those alternatives.
Does consent have to be written?
No. Basic consent (eg, consent to
touching contact during a physical
examination) need not be in writing and
is often implied. An informed consent
should be in writing and documented
in the chart.
Can a physician refuse to treat patients
based on race, financial status, and
presence of mental illness or
HIV status?
Generally, a physician may refuse to
treat a patient as long as the reasons for
refusal are not illegal. Illegal reasons to
refuse treatment include race, national
origin, gender, religion, and disability
(which include mental illness and
HIV status). Except in emergency
situations, a physician may refuse to
treat a patient based upon inability
to pay.
If a patient is homicidal, is a physician
allowed to break patient confidentiality?
Yes. In almost all states, the Tarasoff
decision applies, which requires a
physician to warn the person in severe
danger and notify law enforcement. In
states such as Georgia, Tarasoff has not
been adopted. Instead, the physician
has a duty to prevent harm by the
patient if there is a right to control. In
other words, if a physician has the
legal right to initiate involuntarily
commitment proceedings and fails to
exercise this right, the physician may be
held liable for harm done by the patient
to third parties if the harm was
foreseeable. Georgia has not specifically
recognized a duty to warn, and
thus, a physician may be breaching
confidentiality in warning an
intended victim.
In what other circumstances is a
physician required to break patient
confidentiality by law?
• A patient is considered suicidal
• Reporting child abuse, elder abuse,
or domestic violence (call Child
Protective Services, Adult Protective
Services, or the police)
• Court order (except to the extent the
information is privileged)
• Patient driving without cognitive
abilities to do so (some states
have specific procedures and
forms)
• Reporting certain infectious
diseases, including HIV/acquired
immunodeficiency syndrome
(AIDS)
In what other circumstances
can a physician breach patient
confidentiality?
If the patient signs a written authorization,
the physician may disclose private
health information consistent with the
authorization. State law may also
authorize a physician to share private
health information with specified people
who are at risk for contracting HIV from
a patient. Disclosure of this information
is controlled by state law, and physicians
must proceed carefully because if state
law does not authorize disclosing
HIV/AIDS information, the physician
may be guilty of violating Health
Insurance Portability and Accountability
Act of 1996 (HIPAA) which may result
in fines and a prison sentence.
When can a patient be “committed”
or involuntarily hospitalized?
The process varies by state, but a patient
who presents a substantial risk of
imminent harm to himself or herself or
others, or if a patient is so unable to care
for his or her own physical safety as to
create an imminently life-endangering
crisis, then the patient needs involuntary
inpatient treatment.
If a patient is involuntarily hospitalized,
can a physician administer any
treatment they want?
No. Even an involuntarily committed
patient has the right to refuse medical
treatment.
How do mentally ill patients receive
treatment even if they refuse treatment?
A judge can order the administration
of treatment if the patient is found
incompetent to refuse treatment. Also,
if the patient is violent and posing an
immediate, severe danger to himself or
herself or others, this is considered a
medical emergency and the physician
may administer treatment without the
patient’s consent.
CLINICAL VIGNETTES
Your patient has metastatic lung cancer and he is nearing the last weeks of his life.
He is in considerable pain and is having trouble breathing without being
intubated. His wishes were to not be intubated or having any life-prolonging
measures. His son asks if you can do anything for his pain. You ask the nurse
about giving him more morphine and she says that the respiratory depression will
kill him. Is it ethical to do this?
Yes—it is ethically permissible under the principle of double-effect even if it
causes his death, as long as your primary goal is to treat his pain.
A 72-year-old woman comes in with a gangrenous foot. The orthopedic service
would like to amputate the foot to save her life. You are worried about the risks
involved in the surgery. The man in the bed next door also needs a surgical
procedure, but he is unable to afford it. The woman with the gangrenous foot
doesn’t want the surgery because she wants to keep herself “whole.” Of the four
parties involved in this story (Patient, Orthopedic service, the man next door, and
you), which ethical principles is each representing?
Patient: Patient Autonomy
Orthopedic service: Beneficence
Man next door: Justice
You: Nonmaleficence
CHAPTER 25
Health Care in the
United States
HEALTH-CARE INSURANCE
What is the primary difference in
health-care insurance coverage in the
United States as compared to other
industrialized countries?
The United States is the only industrialized
country without government-funded
health care for all citizens.
What options for insurance coverage
are there and how do most people
get their coverage?
Employer-Sponsored Programs
(most common)
Individual Policy (self-purchased)
Medicare
Medicaid
What is Medicaid?
Government-funded program for
low-income people below a certain
income
What is Medicare?
Government-funded program for those
>65 years or those who are disabled or
those on dialysis
What are the “Parts” of Medicare?
Part A: Hospital coverage
Part B: Outpatient coverage
Part C: Private supplement to A and B
Part D: Prescription drug coverage
Does Medicare have a premium,
co-pay, and/or deductible?
Yes—they vary, but there are outof-pocket expenses for Medicare.
What is the group of people most likely
to be uninsured or have no affordable
available coverage?
Those who are employed, make too much
money to qualify for Medicaid, and do
not receive benefits through their
employer and/or cannot afford
premiums.
191
How many people do not have health
insurance in the United States?
The number continues to rise, but
approximately 45 million plus people.
What are some of the disadvantages
of self-purchased individual
health-care plans?
It may be very difficult to qualify for
these if you have any illnesses. They
can also be prohibitively expensive.
What is “pooled risk”?
Insurance companies make money by
having the average premium of their
insured group be less than the total
amount they pay out for that same
group. Each person has a certain
amount of “risk” for developing
disease. Combining the risk to each
person in a group is “pooling risk.”
What is fee-for-service?
Each service that is done is billed
separately (eg, a doctor visit, x-ray,
lab test, and surgical procedure are
each charged for separately).
Who pays more for the same
service—an uninsured patient
paying out of pocket or an insurance
company?
The uninsured patient. Insurance
companies negotiate discounted rate
with physicians and hospitals—if a
patient pays out of pocket, they have
to pay full price.
What is a Diagnosis-related Group
(DRG)?
With DRGs, a hospital is paid a set
amount for an individual diagnosis, no
matter how long it takes to get better.
For example, Patient A gets pneumonia
and stays in the hospital 2 days, Patient B
gets pneumonia also and takes a 10-day
stay to recover. Medicare pays the hospital
the same $1500 for Patient A as for
Patient B.
What two health-care costs are not
covered by Medicare?
1. Long-term nursing care
2. Outpatient prescription drugs
Which government-funded insurance
plan is funded completely by the
federal government?
Medicare. Medicaid receives funding
from the federal and state governments
both.
What are the primary sources of funding Employee benefit.
for health-care insurance for US citizens? People obtain health-care insurance on
their own.
Which not-for-profit insurance carrier
provides insurance for 30% to 50%
of working citizens in all 50 states?
Blue Cross/Blue Shield
Note: Blue Cross covers hospital costs.
Blue Shield covers diagnostic tests and
physicians’ fees.
Health Care in the United States 193
What are the two primary health plans
offered by private health-care insurers?
1. Fee-for-service plans
2. Managed-care plan
Which type of health-care insurance
plan has high premiums and does not
impose restrictions on provider’s
choice?
Fee-for-service plans
of a health-care managed-care plan?
Low premiums
Restrictions on provider’s choice
What are the types of health-care
managed-care plans?
Health maintenance organization
(HMO)
Preferred provider organizations (PPOs)
Point of service (POS)
What is a health maintenance
organization (HMO)?
An HMO has arrangements with
health-care providers to form a
“network.” The providers give the
HMO a discounted rate in exchange for
receiving health plan referrals. Members
may only see physicians in this network,
otherwise the costs are not be covered
by the plan. Members select a primary
care physician (PCP), often called a
“gatekeeper,” who provides, arranges,
coordinates, and authorizes all aspects
of the member’s health care.
What is meant by a physician being a
“gatekeeper”?
Often the primary care physician (PCP)
in an HMO plan must approve specialist
and ancillary service referrals as well as
coordinate the member’s care.
What are preferred provider
organizations (PPOs)?
PPOs are similar to HMOs in that they
have arrangements with a “provider
network.” Unlike an HMO, members
may choose a doctor outside of this
network, but their coverage will be at a
reduced rate (ie, out-of-pocket expenses
are higher).
HEALTH-CARE COSTS
How does the United States compare
with other countries in terms of
health-care spending?
The United States spends significantly
more per capita and as a percentage
of GDP on health care than any other
nation.
How is the US life expectancy
compared with other countries?
The 2009 CIA (Central Intelligence
Agency) World Factbook ranks
United States at no. 50 out of 224—
despite the increased spending.
Which factors have contributed to the
increase in health-care expenditures?
Larger percentage of elderly individuals
Overuse of medical technology
advances
Medicaid and Medicare expenditures
During what time in a person’s life
span is the most money spent?
The last year of their life
What are the most expensive
components of health care in the
United States (rank items from
most expensive to least expensive)?
1.
2.
3.
4.
5.
6.
7.
Hospitalization
Physician costs
Nursing home costs
Prescription drugs
Medical supplies
Mental health services
Dental and other care
HEALTH-CARE DELIVERY SYSTEMS
What is the role of nursing homes?
To provide long-term care, especially for
individuals aged 65 years and older
What percentage of the elderly population 5%
uses nursing home services?
What is the range of costs spent on an
individual that resides in a nursing
home?
$35,000 to $75,000—depending upon
nursing home level of care
What is hospice care?
A unique type of service provided to
people with terminal illness and a life
expectancy thought to be <6 months.
What are the goals of hospice and
palliative care?
Palliation refers to the treatment of
symptoms rather than a focus on curing
underlying disease. Patients on hospice
generally are given more palliation than
curative interventions.
What is “comfort care” and do hospice
patients have to be on it?
Comfort care refers to administering no
life-prolonging interventions. Hospice
patients generally will not receive
cardiopulmonary resuscitation (CPR)
or other “heroics,” but may receive
nutrition, fluids, antibiotics, and
other appropriate interventions.
Is hospice expensive to the health-care
system?
No—patients generally receive more
services with less expenditure than if
they were to be repeatedly hospitalized.
HEALTH STATUS AND DETERMINANTS
What is the percentage of physical
illness that is due to individual
patterns of living (eg, lack of exercise,
poor dietary choices, and smoking)?
Approximately 70%
What are the primary determinants
of socioeconomic status?
Education level
Which socioeconomic group tends
to delay seeking health care and
present with more progressive
illnesses?
People of low socioeconomic status →
due to lack of funds for health care
Which gender is most likely to seek
medical care?
Female
Which gender has the lowest life
expectancy?
Male
Which group of people has the lowest
life expectancy with regards to race
and gender?
Black males
Which group of people has the highest
life expectancy with regards to race
and gender?
Asian women
Which group of people represents
the fastest growing segment of the
US population?
Elderly
What is the percentage of healthcare costs the elderly population is
responsible for?
30%
Which ethnic minority represents the
largest percent of the US population?
Hispanic
What are the leading causes of death
in the United States, irrespective of
age group?
Heart disease
Cancer
Stroke
Income
Occupation
Residence
What are the three leading causes
of death in infants <1 year of age
(rank in order from most common
to least common)?
1. Congenital anomalies
2. Sudden infant death syndrome (SIDS)
3. Respiratory distress syndrome
of death in children between 1 and
4 years of age (rank in order from
most common to least common)?
1. Accidents
2. Congenital anomalies
3. Cancer
of death in children between 5 and
14 years of age (rank in order
from most common to least
common)?
1. Accidents
2. Cancer
3. Homicide
of death in young adults between
15 and 24 years of age (rank in order
from most common to least
common)?
1. Accidents → mostly motor vehicle
2. Homicide
3. Suicide
of death in adults between 25 and
1. Accidents
2. HIV infections
3. Cancer
of death in adults between 45 and
1. Cancer
2. Heart disease
3. Stroke
of death in elderly over 65 years
of age (rank in order from most
common to least common)?
1. Heart disease
2. Cancer
3. Stroke
CLINICAL VIGNETTES
A law is passed saying that private insurance companies can charge no more than
$250 per month per person it insures. How can this company continue to make
money?
By enrolling only those people who are in excellent health and have low risk of
disease. This is referred to as “cherry picking” or “cream skimming.” Of course, by
taking these healthy people out of the risk pool, those that are left over are sicker
(and riskier) overall—creating a group of difficult-to-insure patients who need care.
A 50-year-old woman is shopping for insurance. She has rheumatoid arthritis and
takes some very expensive monoclonal-antibody agents which keep her very
functional, and would like to keep her own doctor. She is employed making
$60,000 a year and has the option of insurance through her employer. Which
options are best for her: employer-sponsored insurance, individually purchased
plan, Medicare, or Medicaid? HMO or PPO?
She is neither 65 years of age or older nor disabled, so would not qualify for
Medicare. Similarly, she is not low income and would not be eligible for Medicaid.
Since she has a preexisting condition of rheumatoid arthritis for which she takes
expensive medication, an individual plan may be difficult for her to obtain. As
such, employer-sponsored health insurance would be best. The best way to keep
her own doctor would likely be through a PPO, where she could go out of the
provider network if needed to stay with her doctor.
CHAPTER 26
Epidemiology and
Research Design
EPIDEMIOLOGY
What is prevalence?
The total number of individuals who
have a disease in a population at a
specific time or period of time, divided
by the total number of people in that
population.
What is incidence?
The total number of individuals who
are newly diagnosed with a disease
divided by the number of individuals
who are originally at risk (usually
measured over a time period).
What equation represents
the relationship between
prevalence and incidence?
Prevalence = incidence × disease duration
P=I×D
What happens to the prevalence
of a disease as the duration of it is
lengthened, assuming the incidence
is held constant?
It would increase—use the equation.
Which is usually greater in chronic
diseases—prevalence or incidence?
Prevalence is usually greater with long
duration diseases, eg, HIV.
Which is more useful for describing
influenza over the course of a year—
incidence or prevalence?
Incidence. With acute illnesses, duration
is short and prevalence at any given
time is not of as much value as incidence.
The shorter the illness, the closer
prevalence becomes to being equal
to incidence.
199
What is Sensitivity?
The ability of a test to detect disease if it
is present
What is Specificity?
The ability of a test to discern one
disease from another
What is best for a screening test
or to “rule out” disease (low false
negative)?
A test with a high sensitivity
What is best for a confirmatory
test or to “rule in” disease
(low false positive)?
True negatives divided by all of the
people without a disease or illness
What is a good mnemonic to
remember this?
SPin (SPecificity rules in) and SNout
(SeNsitivity rules out)
What is positive predictive value (PPV)?
The likelihood that a positive result on a
test represents actual disease
What is negative predictive value (NPV)?
The likelihood that a negative result on
a test actually represents the absence of
disease
What is the relation between sensitivity,
specificity, NPV, and PPV?
Sensitivity and specificity are directly
related to NPV and PPV (respectively),
but NPV and PPV occur when a test is
applied to a specific population.
sensitivity, specificity, NPV,
and PPV?
Sensitivity and specificity are inherent
properties of a test, regardless of the
population’s disease prevalence. PPV
and NPV are directly dependent on
the population being tested.
How do sensitivity and specificity
affect NPV and PPV?
A high sensitivity will increase NPV of
a test, a high specificity will increase the
PPV of a test.
How does prevalence of disease in a
population affect PPV and NPV?
High prevalence of disease will increase
the PPV and decrease the NPV of a test.
Low prevalence will decrease the PPV
and increase the NPV. (This should
make sense!)
What is the best way to solve problems
requiring the calculation of sensitivity,
specificity, PPV, and NPV?
Use the box method—draw it out and
plug in the numbers for each problem.
Epidemiology and Research Design 201
Actual disease state
+
+
–
a
b
Sensitivity = a/(a + c)
Specificity = d/(b + d )
PPV = a/(a + b)
NPV = d/(c + d )
Test result
–
c
a = True positives
b = False positives
c = False negatives
d = True negatives
d
All patients with disease = (a + c)
All patients without disease = (b + d )
All positive tests = (a + b)
All negative tests = (c + d )
Figure 26.1
How is sensitivity calculated?
True positives divided by all of the
individuals with a disease
Sensitivity = a/(a + c)
How is specificity calculated?
True negatives divided by all of the
people without a disease
Specificity = d/(b + d)
How is positive predictive value
calculated?
True positives divided by all people
with a positive test
PPV = a/(a + b)
How is negative predictive value
calculated?
True negatives divided by all people
with a negative test
NPV = d/(c + d)
RESEARCH STUDY DESIGNS
What is a prospective study?
A research study that starts before
the studied disease or outcome has
happened, and usually monitors for
its development.
What is a retrospective study?
A research study that starts after the
studied disease or outcome has
happened, and usually looks back
for factors that led to it.
What is meant by a study being
“observational”?
The researcher separates subjects into
groups and merely waits for the
outcome in question to happen.
What is meant by a study being
“experimental”?
The researcher separates subjects into
groups and applies an intervention to
one or more of those groups, hoping
to modify the outcome.
What is a case-control study?
An observational study that compares
subjects who have a disease or outcome
(cases) with subjects who do not have
an illness or outcome (controls).
Note: Groups are divided based on
disease presence (outcome).
What is a cohort study?
An observational study that compares
subjects with and without a certain risk
factors or exposure. This study then
follows subjects for the development
of disease.
Note: Groups are divided based on risk
factor (exposure).
What are the two types of cohort studies?
1. Prospective
2. Retrospective
What is a prospective cohort study?
A prospective cohort study evaluates a
cohort of individuals after they have
experienced the risk factor/exposure,
but before development of disease/
outcome. (Eg, a study is constructed to
evaluate whether children exposed to
secondhand smoke at birth will be more
susceptible to lung cancer than those
children not exposed, started when
children are 5 years old).
What is a retrospective cohort study?
A retrospective cohort study evaluates a
cohort of individuals after both the risk
factor/exposure and the disease/outcome
have happened. (Eg, a study of if children
exposed to secondhand smoke at birth
will be more susceptible to lung cancer
than those children not exposed, started
at age 80).
What is a cross-sectional study?
A descriptive study (neither observational
nor experimental) that compares subjects
in respect to both risk factor/exposure
and disease/outcome at one specific point
in time.
What is a clinical trial?
An experimental study in which groups
of subjects are given different treatments
or interventions to determine if there is
an effect.
Note: Often there is an experimental
group that receives the studied
intervention and a control group that
receives either placebo or a different
“standard” treatment.
What are two primary characteristics
of high-quality clinical trials?
They are double-blinded and patients
are randomized to be in either the
experimental or control group.
TESTING
What are the attributes of useful testing
instruments?
Lacks bias
Reliably Valid
Name the types of bias that may be
prevalent in a research study.
Admission rate bias
Lead time bias
Nonresponse bias
Sampling bias
Selection bias
Which bias can occur when hospital A
admits sicker patients than hospital B?
Admission rate bias
Which bias can occur when a disease
or illness is detected earlier, leading
to seemingly increased survival time?
Lead time bias
Which bias can occur when people fail
to return surveys or respond to a phone
or email survey?
Nonresponse bias
Which bias can occur when a study
favors selecting subjects that have
a particular characteristic or set of
characteristics?
Sampling bias
Which bias can occur if the subjects
studied are not representative of the
target population about which
conclusions are drawn?
Selection bias
What percentage of patients generally
respond to placebos?
Usually at least 33% of patients
What happens to the response rate to
placebos in psychiatric conditions?
It increases in psychiatric illnesses.
What is the definition of a doubleblind study?
A study in which neither the research
scientist nor the subject knows which
participants are in the experimental
group and which are in the control
group.
If initially group A receives a treatment
and group B receives a placebo and
later the protocol is switched so that
group A receives the placebo and
group B receives a treatment,
what type of research study is
being utilized?
Crossover studies
What is reliability?
It is the reproducibility of a given test.
What type of reliability is demonstrated
when different examiners are able to
achieve test results that are similar?
Interrater reliability
What type of reliability is demonstrated
when subsequent tests yield similar
results to initial tests?
Test-retest reliability
What is the definition of validity?
It determines whether a test measures
what it is supposed to measure.
What is the definition of precision?
It is the consistency and reproducibility
of a test. On a dartboard, it would be
hitting the same place over and over
(though not necessarily the correct
place).
What is the definition of accuracy?
It determines how true test measurements
are. On a dartboard, it would be hitting
the correct place (though perhaps not
consistently).
MEASURES OF ASSOCIATION
Which measures are used to quantify
risks in population studies?
Relative risk
Attributable risk
Odds ratio
Which measure(s) of association is used
to evaluate cohort studies?
Relative risk
Attributable risk
Which measure(s) of association is used
to evaluate case-control studies?
Odds ratio
How does our four-box method
for calculating specificity and sensitivity
change when calculating risk?
The left heading of “test result” is
changed to “exposure/risk factor”
(the top heading stays the same).
Disease state
+
+
–
a
b
RR = ([a/(a + b)] / [c/(c + d )] )
AR = ([a/(a + b)] – [c/(c + d )] )
OR = ad/bc
Exposure/risk
factor
–
c
a = Exposed subjects with disease
b = Exposed subjects without disease
c = Unexposed subjects with disease
d = Unexposed subjects without disease
d
All with disease = (a + c)
All without disease = (b + d )
All exposed = (a + b)
All unexposed = (c + d )
Figure 26.2
What is relative risk (RR)?
RR is a measure of the likelihood of
disease in exposed subjects compared
to unexposed. It is expressed as a ratio,
so an RR = 1.0 is the risk of the
unexposed subjects.
How is RR calculated?
It is the incidence of disease in the
exposed group divided by the incidence
of disease in the unexposed group.
RR = [a/(a + b)]/[c/(c + d)]
At what value is RR significant?
When RR is greater than or less than 1.0
If the RR is >1, what can be said about
the risk?
There is an increased risk of the disease
or illness.
If the RR is <1, there is a decreased risk
of illness or disease.
What is the definition of Attributable
Risk (AR)?
AR is used to determine how much risk
is caused by a single risk factor (eg, how
likely is a high cholesterol diet to lead
to atherosclerosis?).
How is AR calculated?
AR is the disease rate in exposed
subjects minus that in unexposed
subjects.
AR = [a/(a + b)] − [c/(c + d)]
If the incidence rate of atherosclerosis
in the general population in Atlanta,
GA is 10/100 and in individuals with a
high cholesterol diet is 50/100, what is
the attributable risk?
40/100 → This answer assumes that
there is a properly matched control.
What is an odds ratio (OR)?
This determines the relative risk if the
prevalence of disease is low.
OR = (a/c)/(b/d) = ad/bc
How can you interpret odds ratio in
comparison to relative risk?
In most situations, odds ratio is a
reliable way to estimate relative risk
(interpret them the same).
What would be concluded about a study
if the 95% confidence interval for RR
or OR crosses 1?
There would not be a statistically
significant result of the study (p = >0.5).
CLINICAL VIGNETTES
How have advances in antiretroviral therapies influenced the prevalence of HIV,
assuming incidence of HIV has remained constant?
HIV has an increased prevalence due to the lengthening of life expectancy of
infected patients. Using P = I × D, and assuming the medications have little effect
on incidence, as duration is increased, so is prevalence. (Note that HAART does
significantly decrease the transmission of HIV.)
If you are told that almost all children with chickenpox have a fever, but that fever
can be a feature of many illnesses. How would you describe fever in terms of
sensitivity and specificity in regards to chickenpox?
Sensitivity would be high (someone without fever would be unlikely to have
chickenpox), specificity would be low (fever could be from many diseases).
Two groups of male patients are looked at over a 10-year period, ones that like to
go to the doctor regularly for checkups and ones that don’t get much care at all. It
is found that the group which goes to the doctor regularly has a longer survival
time after diagnosis of prostate cancer than the ones who don’t get much care.
What type of study design is this? What type of measure of risk would you use to
compare the groups? What is a likely potential type of bias in this study?
This is a cohort study—it separates groups based on the risk factor/exposure of
health-care utilization and then monitors for the development of disease and
death. Cohort studies use relative risk measures (as opposed to case-control
studies which use odds ratios). This study likely suffers from lead time bias as the
survival time after diagnosis is directly dependent on how early a patient is
screened for disease—likely more often for those going to the doctor regularly.
A new laboratory test for depression is developed. Nearly 2500 patients are tested,
800 with depression and 1700 without depression. There are 720 true positives,
1500 true negatives, 80 false negatives, and 200 false positives. What is the
sensitivity of test? What is the specificity of the test? If a patient from this same
population tests positive for depression, how certain are you that the patient
actually has depression? How about if the same patient tested negative—how sure
are you that he/she doesn’t have depression?
First off, make a four-box diagram, as done below. You should start with this every
time. The bold numbers are row and column totals. Remember that a is true
positives, b is false positives, c is false negatives, and d is true negatives.
Disease
+
Exposure
−
+
720
200
920
_
80
1500
1580
800
1700
2500
For the first two questions, plug in numbers. Sensitivity = 720/(80 + 720) = 90%.
Specificity = 1500/(1500 + 200) = 88%. The second two questions are really asking
you to calculate the positive predictive value and negative predictive value,
respectively. PPV = 720/(720 + 200) = 78%. NPV = 1500/(1500 + 1580) = 95%.
CHAPTER 27
Biostatistics
STATISTICAL DISTRIBUTION
What are the three measures of central
tendency?
1. Mean
2. Median
3. Mode
What is the definition of mean?
The average of a set of numbers
What is the definition of median?
The middle number in a set of numbers
when they are put in sequential order
Note: If there is an even amount of
data in a set, the median is the
average of the two middle values
in the data set.
What is the definition of mode?
The number that appears most
frequently in a set of numbers.
Using the following set of numbers,
what are the mean, median, and mode?
1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 12
Mean = [(1 + 2 + 3 + 4 + 5 + 6 + 7 + 8 +
9 + 10 + 11 + 12 + 12)/13] = 90/13 = 6.923
Median = 7
Mode = 12
What is the range of a data set?
The difference between the highest and
lowest values in a data set
Note: The range in the data set above is
12 − 1 = 11.
Define normal distribution.
A set of numbers in which the mean,
median, and mode are equal.
Mean = median = mode
What type of curve demonstrates
a normal distribution?
Gaussian or bell-shaped curve
209
When a data set shows a large number
of high values and a small number
of low values, what is the distribution
of the data set?
Negatively skewed
Mean < median < mode
Note: The tail of the curve is on the left
or on the negative end of the number line.
When a data set shows a large number
of low values and a small number of
high values, what is the distribution
of the data set?
Positively skewed
Mean > median > mode
When a data set shows two humps,
what is the distribution of the data set?
Note: The tail of the curve is on the
right or on the positive end of the
number line.
Bimodal
Normal distribution
Bimodal distribution
Positively skewed
Negatively skewed
Figure 27.1 Statistical frequency distributions.
What is a variable?
It is a quantity that changes throughout
time.
What is an independent variable?
It is an attribute that the research
scientist may adjust in an experiment.
Biostatistics 211
What is a dependent variable?
It is the outcome that is measured and
affected by the experiment.
How do I remember this?
The dependent variable is dependent on
the independent variable.
What is the correlation coefficient (r)?
It expresses the strength of a relationship
between two variables. Its value must
be between −1.0 and +1.0.
Note: The minus sign (−) implies a
negative correlation and the plus sign
(+) implies a positive correlation.
Why is it important to take the absolute
value of the r?
The absolute value of r will determine
the strength of the correlation.
What is the definition of standard
deviation (σ)?
It is the root mean square deviation from
the average. The standard deviation is
defined as the square root of the variance.
How is standard deviation used?
It is a measure of how dispersed a data
set is around the mean. With a large σ,
data will be more spread out than with a
small one—even if the mean is the same.
0.15%
2.35%
−3
13.5%
−2
34.0%
−1
34.0%
Mean
13.5%
+1
+2
2.35%
0.15%
+3
68%
95%
99.7%
Figure 27.2 Normal (Gaussian) distribution represented by a Bell-Shaped Curve. The (+) and (−)
numbers under the curve correspond to the standard deviations from the mean.
What percentage of data falls in
1 standard deviation from the mean?
68%
2 standard deviations from the mean?
95%
3 standard deviations from the mean?
99.7%
STATISTICAL HYPOTHESIS AND ERROR TYPES
What is meant by “null hypothesis
testing”?
The idea that, by default, there are no
relationships between variables. Research
must then be done to disprove this—
called “rejecting the null.”
What is the null hypothesis (H0)?
A hypothesis stating that there is no
difference between an experimental
and control group. (ie, variables are
unrelated)
What is the alternative hypothesis (H1)?
A hypothesis stating a relationship
between variables, or an effect on an
experimental group different than the
control group. If this was true, you
would “reject the null.”
Which would be true if there was no
effect in your research study?
You would accept the null hypothesis.
Which would be true if there were an
effect in your research study?
You would reject the null hypothesis.
What is a type I (α) error?
A type I error rejects the null when the
null is actually correct—this type of
error says there is an effect when there
actually is not. A “False-Positive.”
Related to p-value.
What is a type II (β) error?
A type II error does not reject the null
when the alternative hypothesis is
actually correct—this type of error does
not detect an effect when there actually
is one. A “False-Negative.”
What is power?
It is the probability of rejecting the null
hypothesis when it is indeed incorrect.
This is the study’s ability to detect an
effect, if present.
Biostatistics 213
If the sample size increases, what
happens to power?
It increases.
What is statistical significance?
That the probability of an observed
effect being due solely to chance is low
enough that the effect is likely true.
What is the probability (p) value?
It is the percent chance that an effect
seen between variables or in an
experimental group was due to chance
alone. For example, if p = 0.25, there is a
25% chance that the effect seen was just
by chance (a type I error).
What p value is most commonly
considered a cutoff to determine
statistical significance?
p <0.05
What is the confidence interval (CI)?
It is an estimated range of values
which is likely to include an unknown
population parameter, the estimated
range being calculated from a given
set of sample data.
What is the point of p values and
confidence intervals?
In research, we are looking for the true
value of the particular effect of one
variable on another variable. P values
and CI express the probability that the
data we get from research is the true
value of that effect.
What is a way to state in words a
95% confidence interval?
If the study was repeated an infinite
number of times, 95% of the time this
interval would contain the true value.
(Therefore there is only a 5% chance
that the true value sought is outside
of this interval.)
How is the CI related to the p value?
Closely! They are two ways of
describing the probability of an
observed effect being due to chance.
Can I guess the approximate p value
from the CI?
Yes—a 95% confidence interval that
does not contain the reference value
(eg, 0 or 1.00 for relative risk/odds
ratio) will have a p <0.05.
What’s the big deal about a 95% CI
“crossing 1” or “crossing 0”?
This would mean p >0.05, and the
effect would not be “statistically
significant.”
STATISTICAL TESTS
What types of data are evaluated
in statistical tests?
Nominal
Ordinal
Interval
Ratio
What is nominal data?
It is categorical data where the order of
the categories is arbitrary (eg, gender,
religious beliefs).
What is ordinal data?
It is categorical data where there is a
logical ordering to the categories
(eg, first place winner, second place
winner, third place winner, etc).
What is interval data?
It is continuous data where there is a
set interval between values, but where
there is no “natural” zero (eg, Celsius,
Fahrenheit).
What is ratio data?
It is continuous data where there is both
a set interval between values and a
natural zero (eg, weight, height).
What type of common statistical
tests is used to analyze nominal or
ordinal data?
Chi-square
What types of statistical tests are used
to analyze interval or ratio data?
t-test
Analysis of variance (ANOVA)
Linear correlation
parametric and nonparametric
statistical tests?
Parametric tests analyze data with a
normal distribution. Nonparametric
analyze data sets without a normal
distribution.
What type of parametric statistical test
determines the difference between
the means of two groups?
t-test
Which type of t-test evaluates the means
of two groups at one period of time?
Independent (nonpaired) t-test
(eg, comparing the mean income of one
set of orthopaedic surgeons, Group
Bone, to the mean income of another set
of orthopaedic surgeons, Group Tendon,
at the beginning of the calendar year)
Biostatistics 215
Which type of t-test evaluates
the means of two groups at two
different time periods?
Dependent (paired) t-test (eg, comparing
the mean income of one set of
orthopaedic surgeons, Group Bone,
to the mean income of another set of
orthopaedic surgeons, Group Tendon, at
the beginning and in the middle of the
calendar year)
Which type of parametric
statistical test determines the
difference of means of more
than two groups?
ANOVA
Which type of ANOVA test
determines the difference of
means of more than two groups
using only one variable?
One-way ANOVA (eg, comparing the
mean income of orthopaedic surgeons
in Group Bone, Group Tendon, and
Group Ligament at the beginning of
the calendar year)
Which type of ANOVA test
determines the difference of
means of more than two groups
using two variables?
Two-way ANOVA (eg, comparing the
mean income and malpractice insurance
rate of orthopaedic surgeons in Group
Bone, Group Tendon, and Group
Ligament at the beginning of the
calendar year)
Which type of parametric
statistical test determines the
relation between two continuous
variables?
Linear correlation
What are some examples of
nonparametric tests?
Mann-Whitney U
Wilcoxon’s
CLINICAL VIGNETTES
A cohort study is done to relate amount of vegetables eaten per day with the
development of diabetes. It is found that the group who is fed five servings per
day of vegetables has a Relative Risk of 0.65 (95% CI = 0.40 − 0.95) for developing
diabetes (control group having RR = 1.00).
What is the independent variable?
The independent variable is amount of vegetables eaten (the manipulated variable).
What is the dependent variable?
The dependent variable is development of diabetes (dependent on vegetables eaten).
Are the results statistically significant?
The results are statistically significant as the CI does not cross 1.00 (the control value).
Is the p-value greater than or less than 0.05?
The p-value would be <0.05 (less than a 5% probability of the result due to chance
alone).
Should the researchers accept or reject the null?
Researchers may reject the null hypothesis.
A research team at a tobacco company takes three subjects who smoke 1 pack per
day and follows them over 25 years to monitor for the development of lung cancer.
None of the subjects develop cancer. The researchers conclude that tobacco does
not cause lung cancer (which is not true).
Did they reject or accept the null?
The researchers have accepted the null hypothesis, when in fact there was an effect
and the null should have been rejected.
What type of error has their research committed?
They committed a type II (β) error.
How can they improve the power of their study?
Power can be most easily improved by increasing the number of subjects in the study.
Taste testers are asked to rate different hot sauces as poor, fair, good, or excellent.
What type of data is being is collected? What would be a good statistical test to
analyze this data?
The data is ordinal—it has a logical order to it, but the intervals between the
categories are not well defined. A Chi-square would be appropriate.
Index
Alcohol abuse, withdrawal (Cont.):
hallucinations, 150
seizures, 150
symptoms, 150
α (type I) error, 212
Alternative hypothesis (H1), 212
Altruism, as defense mechanism, 27, 30
Alzheimer disease
brain changes, postmortem, 114
cholinergic neuron decrease, 81
clinical course, 113
dementia and, 113–114
genetic factors, 71
medications, 114
neuropeptides, 82
risk factors, 114
sleep patterns, 48
vascular dementia v., 113
Amenorrhea, 153
from antipsychotics, 172
Amines, 78–81. See also Acetylcholine;
Dopamines; Serotonin
γ -Aminobutyric acid (GABA), 63, 81
Amnestic syndromes, 115
brain structures affected, 115
dementia v., 115
Amphetamines, 55, 144. See also Substance
abuse
Amygdala lesion, 76
Anaclitic depression, 11
Anal phase, 4
Analysis of variance (ANOVA), 214–215
Androgen insensitivity, 50
Anemia, 153–154
Anger, as stage of dying, 21
Anhedonia, 93, 141
Anorexia nervosa, 121, 153–154
bulimia nervosa v., 153
medical effects of, 153–154
treatment, 154
ANOVA (analysis of variance), 214–215
Antipsychotics, 171–172
amenorrhea from, 172
antitypical
mechanism of action, 171
side effects, 171
for delirium, 112
histamine blocking, 80
for NMS, 91
for schizophrenia, 90
A
Abnormal thought formation, 88
Abuse. See also Substance abuse
child, 57–60
domestic partner, 60
elder, 57–60
emotional, 59–60
sexual, 58–59
Acceptance, as stage of dying, 21
Accuracy, 204
Accutane, 94
Acetylcholine, 80–81
Acting out, as defense mechanism, 30
Active suicidal ideation, 67
Acute stress disorder (ASD), 103, 108
ADHD (attention-deficit hyperactivity
disorder), 162
Adjustment disorder, 108–110
Adolescence, 12
Adoption, children’s knowledge of, 12
Adoption study, 69
Adulthood, 15–17
Advance directive, 184
Aggression, 62–63
Aging, 19–20. See also Elderly
memory and, dementia v., 113
physiologic changes, in males, 17
Agnosia, 112
Agoraphobia, 103, 105
Agranulocytosis, 171–172
Alcohol abuse, 148–150. See also Substance
abuse
chronic effects, 149
ethanol
liver metabolism limits, 149
toxicity, 143
genetic factors for, 72
HVA and, 79
relapse rate, 150
screening for, 148
sexual response and, 55–56
thiamine deficiency, 115
tolerance types, 149
toxic effects, 149
in twins, 72
withdrawal, 141, 143
with benzodiazepines, 150
benzodiazepines for, 166
with disulfiram, 141
DTs, 150
217
218
Antipsychotics (Cont.):
therapy, side effects of, 172
typical
extrapyramidal effects, 171
side effects, 171
Antisocial personality disorder, 29,
127–128, 161
genetic factors, 71
treatment, 128
Anxiety disorders, 103–110
adjustment disorder, 108–110
agoraphobia, 103
ASD, 103
GAD, 103–104
genetic factors, 71
OCD, 103
panic disorder, 103–105
PTSD, 103
social phobia, 103
specific phobia, 103
suicide, 66
Anxiolytics, 165
Aphasia, 112
Apolipoprotein E4, 71
Apomorphine, 53
Apraxia, 112
AR (attributable risk), 206
Artificial life support, 186
ASD (acute stress disorder), 103, 108
Asperger disorder, 159–160
Association, 205–206
Associative learning, 35–39
classical conditioning, 35–37, 36f
imprinting, 35–36
nonassociative v., 35
operant conditioning, 35, 37
Asymmetric tonic neck, 6
Atomoxetine, 162
Attachment, 11–12
Attention-deficit hyperactivity disorder
(ADHD), 162
Attributable risk (AR), 206
Autistic disorder, 159–160
Avoidance, as defense mechanism, 30
Avoidant personality disorder, 71, 130–131
B
Barbiturates, 81, 167
Bargaining, as stage of dying, 21
Basal ganglia lesion, 76
Beneficence, 181
Benzodiazepines
for alcohol withdrawal, 150, 166
for anxiety, barbiturates v., 167
anxiolytics, 165
delirium from, 111
Index
Benzodiazepines (Cont.):
GABA channel opening, 81
for GAD, 104
high potency, 166
hypnotics, 165
lack of tolerance development, 165
low potency, 166
metabolism phases, 166
during pregnancy, 165
reversal of effects, 165
side effects, 166
for sleep disorders, 47
for social phobia, 107
withdrawal symptoms, 166
Bereavement, 21–22, 22t
β (type II) error, 212
Beta-blockers, 94
Bias, 203–204
Biostatistics, 209–216
Bipolar disorder, 66, 91, 99, 101
mood stabilizers for, 100t
pharmacologic agents, 172–173
during pregnancy, 173
prevalence, 101
types, 99, 101
Body dysmorphic disorder, 106, 121
Borderline personality disorder, 29, 128–129
diagnostic criteria, 128
genetic factors, 71
splitting, 128
treatment, 129
Brain, 75–77
amnestic syndromes’ effects on, 115
lesions, 76–77
consequences, by location, 76–77
neuroanatomy, 75–76
schizophrenia and, physical changes
from, 89
Brief psychotic disorder, 86, 88
Bulimia nervosa, 153–155
anorexia nervosa v., 153
medical effects, 155
treatment, 155
Buprenorphine, 146
Bupropion, 96t, 168
Buspirone, 104, 167
C
Caffeine, 143
Carbamazepine, 100t, 173
Carbatrol. See Carbamazepine
Catalepsy, 90
Catatonic schizophrenia, 89
Catecholamine, 78–79
CBT (cognitive behavioral therapy), 106
CCK (cholecystokinin), 82
Index
Celexa. See Citalopram
Central nervous system (CNS), 75–76
Child abuse, 57–60
burns from, typical, 58
fractures from, typical, 57
leading causes of death, 196
sexual, 58–59
age range, 59
by gender, 59
incidence rates, 58
physical signs, 59
psychological signs, 59
shaken baby syndrome, 58
traits of abusers, 57
Child neglect, 57
Childbirth. See Pregnancy and childbirth
Childhood disintegrative disorder, 159, 161
Children
adoption, knowledge of, 12
developmental milestones, 6–8, 9–11t
legal consent for, 185
neuropsychiatric disorders, 159–164
ADHD, 162
disruptive behavior disorders, 161
pervasive development disorders,
159–161
selective mutism, 163
separation anxiety disorder, 163
Tourette disorder, 72, 162–163
understanding of death, 12
Cholecystokinin (CCK), 82
CI (confidence interval), 213
Circadian rhythm sleep disorder, 45, 47
Citalopram, 95t, 167
Classical conditioning, 35–37, 36f, 39
Climacterium, 17
Clinical trial, 203
Clomipramine, 106
Close-ended questions, 179
Clozapine, 171–172
CNS (central nervous system), 75–76
Cocaine, 55, 144. See also Substance abuse
Codeine, 146
Cognitive behavioral therapy (CBT), 106
Cognitive disorders, 86, 111–116. See also
Delirium; Dementia
amnestic syndromes, 115
delirium, 111–112
dementia, 20, 112–114
Cohort study, 202
Coining, 58
Commitment, of patients, 188
Competence, 183
Compliance. See Patient adherence
Compulsions, 106
Concordance, 69
Conduct disorder, 127, 161
219
Confidence interval (CI), 213
Confidentiality, patient, 178, 187–188
Congenital adrenal hyperplasia, 50
Coning, 180
Conscious, as part of mind, 25
Consent, 184, 186
Continuous reinforcement, 39
Conversion disorder, 117t, 119–120
Correlation coefficient (r), 211
Countertransference, 30
Cravings, 142
Cross-sectional study, 203
Crystallized intelligence, 20
Cupping, 58
Cyclothymic disorder, 101
Cymbalta. See Duloxetine
CYP2D6, 146–147
D
Data sets, 210
Death and dying
bereavement, 21–22, 22t
children’s understanding of, 12
five stages, 21–22
Defense mechanisms, 26–30, 31–32t
Delirium, 111–112
causes, 111
definition, 111
dementia v., 114t
treatment, 112
Delirium tremens (DTs), 150
Delusional disorder, 86, 91
Dementia, 20, 112–114. See also Alzheimer
disease
amnestic syndromes v., 115
core symptoms, 112
delirium v., 114t
memory and aging v., 113
prevalence, 113
types, 113–114
vascular, 113
Denial
as defense mechanism, 29–30
as stage of dying, 21
Depakote. See Valproic acid
Dependent personality disorder, 131–132
Dependent variables, 211
Depersonalization disorder, 136
Depression. See also Major depressive
disorder
anaclitic, 11
bereavement, 22, 22t
body dysmorphic disorder and, 121
double, 94
ECT for, 173
in elderly, 20
220
Depression (Cont.):
HVA and, 79
learned helplessness and, 37
mnemonic for, 93
monoamine theory, 78
postpartum, 16, 94
serotonin levels, 47
sleep disorders, 47–48
as stage of dying, 21
suicide and, 67
treatment, 94–95, 95t, 96t
for postpartum, 16
with SSRIs, 94, 95t, 167
Desyrel. See Trazodone
Detoxification, 142
Development
through adolescence, 12
milestones, 6–8, 9–11t
Tanner stages, 12, 13t
theories, 3–5
Developmental retardation, 11
Dextromethorphan, 146
Diabetes, sexual dysfunction and, in males,
55
Diagnosis-related group (DRG), 192
Diazepam, 167
Disorganized speech, 87
Displacement, as defense mechanism, 27–29
Disruptive behavior disorders, 161
Dissociation, as defense mechanism, 27
Dissociative amnesia, 135
Dissociative anesthetics, 144. See also
Substance abuse
Dissociative fugue, 135–136
Dissociative identity disorder, 136
Disulfiram, 141
Dizygotic twins, 69, 72
Do not resuscitate (DNR) order, 185
Domestic partner abuse, 60
Donepezil, 81, 114
Dopamine hypothesis, 89
“dopamine reward pathway,” 140
Dopamines, 78–79
aggression and, 63
HVA and, 79
for psychiatric conditions, 78
sexual response and, 55
Double-blind study, 204
Down syndrome, 71, 81
Downward drift, 89
DRG (diagnosis-related group), 192
Drug(s). See also specific drugs
first-order elimination, 149f
manic episodes from use of, 101
sexual function and, 55–56
withdrawal from, 141–142
zero-order elimination, 148, 148f
Index
DTs (delirium tremens), 150
Duloxetine, 97t
Dyspareunia, 52
Dyssomnias, 45–46
Dysthymic disorder, 94
E
Early adulthood, 15–16
Eating disorder(s), 153–157
Eating Disorder Not Otherwise Specified
(NOS), 156
Echolalia, 88
ECT (electroconvulsive therapy),
98–99, 173
Effexor. See Venlafaxine
Ego, 25
Elder abuse, 57–60
Elder neglect, 58
Elderly, 19–23
demographics, 19
life expectancy, 19
longevity factors, 21
physiological changes, 19–20
psychological characteristics, 20
psychopathology, 20–21
Electroconvulsive therapy (ECT),
98–99, 173
Emancipated minors, 183
Emotional abuse, 59–60
Endogenous opioids, 82
Endorphins, 81
Enkephalins, 81
Epidemiology, 199–201
Epilepsy, 81
EPS (Extrapyramidal symptoms), of
schizophrenia, 90–91
Equetro. See Carbamazepine
Erikson, Erik, 3–4
Error types, 212–214
Errors. See Medical errors
Escitalopram, 95t
Eskalith. See Lithium
Estrogens, 51
Ethanol
glutamate receptors, 147
mechanisms of action, 147
toxicity, 143
Ethics, medical, 181–189
Ethylamine, 78, 80
Etorphine, 146
Euthanasia, 186
Excitatory neurotransmitters, 77
Exhibitionism, 54
Experimental study, 202
Extinction, 37–38
Extrapyramidal symptoms (EPS),
of schizophrenia, 90–91
Index
F
Factitious disorder, 117, 117t, 122–123
Factitious disorder by proxy, 122–123
Failure to thrive, 11
Family risk study, 69
Fatigue, 93
Fentanyl, 146
Fetal alcohol syndrome, 143
Fetishism, 54
First-order elimination, of drugs, 149f
Five stages of death and dying, 21–22
5-HIAA (5-Hydroxyindoleacetic acid), 80
5-HT (5-hydroxytryptamine), 79
Fixation, as defense mechanism, 27
Flooding, 40, 109
Flumazenil, 165
Fluoxetine, 95t, 167–168
Fluvoxamine, 167
Fragile X syndrome, 72
Free association, 27
Freud, Sigmund. See also Psychoanalytic
theory
developmental theory, 3–4
structural mind theory, 25
topographic mind theory, 25
Frontal lobe lesion, 76
Frotteurism, 54
G
GABA (γ -Aminobutyric acid), 63, 81
GAD (generalized anxiety disorder),
103–104
Ganser syndrome, 123
Gender identity, 49
Gender identity disorder, 49, 121
Gender roles, 49
Generalized anxiety disorder (GAD),
103–104
Genetic studies, 69
Genetics, 69–73
alcoholism and, 72
neuropsychiatric disorders and, 71–72
psychiatric disorders and, 69–71
Genital phase, 4
Glutamate, 81, 147
Glycine, 81
H
H0 (null hypothesis), 212
H1 (alternative hypothesis), 212
Habituation, 40
Hallucinations, 85–86
alcohol withdrawal, 150
illusions v., 86
Haloperidol, 112
Health maintenance organization (HMO),
193
221
Health status, determinants for, 195–196
Health-care costs, 193–194
Health-care delivery systems, 194–195
Health-care insurance, 191–193
coverage, 192
government programs, 191–192
private, 193
types, 191–192
Health-care managed-care plans, 193
Heroin, 56, 146. See also Substance abuse
Himmelsbach hypothesis, for substance
abuse, 140
Hippocampus lesion, 76
Histamines, 80
Histrionic personality disorder, 29, 71, 130
HIV (human immunodeficiency virus),
113, 182
HMO (health maintenance
organization), 193
Homicide, 62
Homosexuality, chromosomal factors, 50
Homovanillic acid (HVA), 79
Hormones, behavior influenced by, 51
Hospice care, 194–195
Human immunodeficiency virus (HIV),
113, 182
Humor, as defense mechanism, 27–28
Huntington’s Disease, 71, 113
HVA (Homovanillic acid), 79
Hydromorphone, 146
Hypertensive crisis, 98
Hypnotics, 165
Hypoactive sexual desire, 52
Hypochondriasis, 120
Hypomania, 99
Hypothalamus lesion, 76–77
Hypotheses, 212–214
I
Id, 25
Identification, as defense mechanism, 27, 29
Illusions, 86
Immature defense mechanisms, 27
Impotence, 52
Imprinting, 35–36
Incidence, 199
Incompetence, in patients, 183
Independent variables, 210
Indolamines, 78
Infants. See also Neonates
developmental milestones, 6–8, 9–11t
morbidity and mortality, 5
leading causes, 196
Informed consent, 186
Inhibitory neurotransmitters, 77
Insomnia, 45–46, 167–168
Insurance. See Health-care insurance
222
Intellectualization, as defense mechanism,
27–28
Intelligence quotient (IQ), 41
Intelligence tests, 41
Interferon, 94
Interpreters, 179
Interrater reliability, 204
IQ (intelligence quotient), 41
Isolation, as defense mechanism,
27–28
J
Justice, 181
K
Kappa receptor agonists, 146
Kappa receptor antagonists, 146
Ketamine, 144. See also Substance abuse
Kleine-Levin syndrome, 46
Kubler Ross, Elizabeth, 21–22
L
Lamictal. See Lamotrigine
Lamotrigine, 100t, 173
Lanugo, 153–154
Latency phase, 4
Learned helplessness, 37
Learning theory, 35–42
associative, 35–39
classical conditioning, 35–37, 36f
operant conditioning, 35, 37
nonassociative, 35, 39–41
habituation, 40
observational learning, 39
Leukopenia, 153–154
Levodopa, 111
Lexapro. See Escitalopram
Life expectancy, 19
Linear correlation, 214–215
Lithium, 100t, 172
Living wills, 185
Longevity, 21
Loperamide, 147
Lorazepam, 167
M
Major depressive disorder, 66, 91, 93–98
dysthymic disorder v., 94
genetic factors, 70
MAOIs, 98
from medications, 94
prevalence, 93
psychotherapy treatments, 98–99
suicidal ideation, 93
symptoms, 93
TCAs, 97–98
treatment for, 94–95, 95t, 96t
Index
Malingering, 117, 117t, 122, 123
Malpractice, 181–182
Mania, 99, 101
Mann-Whitney test, 215
MAOIs. See Monoamine oxidase inhibitors
Marijuana, 55–56, 144–145. See also
Substance abuse
Marriage, 15
Mature defense mechanisms, 27
Mean, 209
Median, 209
Medicaid, 191
Medical errors, 177
Medical ethics, 181–189
Medicare, 191–192
Melanosis coli, 154
Memantine, 114
Menopause, 17
Mental age, 41
Mental retardation, 41
Meperidine, 146
Methadone, 56, 147. See also Substance abuse
3-Methoxy-4-hydroxyphenyglycol (MHPG),
79
Methyldopa, 94
N-methyl-D-aspartate (NMDA), 114
Methylphenidate, 162
MHPG (3-Methoxy-4-hydroxyphenyglycol),
79
Middle adulthood, 17
Mirtazapine, 96t, 104
Mode, 209
Modeling, in nonassociative learning, 39–40
Monoamine oxidase inhibitors (MAOIs),
67, 170
drug interactions, 170
side effects, 170
Monoamine theory of depression, 78
Monozygotic twins, 69–72
Mood disorders, 86
Mood stabilizers, 100t
Moro reflex, 5–6
Morphine, 146
Mu receptor agonists, 146
Mu receptor antagonists, 146
N
Nalorphine, 146
Naltrexone, 146
Namenda. See Memantine
Narcissistic personality disorder,
121, 129–130
Narcolepsy, 45–46, 86
Narcotic overdose. See Overdose, narcotic
Necrophilia, 54
Nefazodone, 96t
Index
Negative predictive value (NPV), 200, 201f
Negative reinforcement, 37–38
Neologisms, 88
Neonates. See also Infants
reflexes, 5–6
Neuroanatomy, 75–76
Neuroleptic malignant syndrome (NMS), 91
Neuropeptides, 81–82
Neurotensin, 82
Neurotransmitters, 77–78
alterations in psychiatric conditions, 78t
release steps, 77
NMDA (N-methyl-D-aspartate), 114
NMS (neuroleptic malignant syndrome), 91
Nominal data, 214
Nonassociative learning, 35, 39–41
Nonmaleficence, 181
Nonrapid eye movement (NREM), 43–45
Norepinephrine
aggression and, 63
as biogenic amine, 79
MHPG, 79
synthesis, 79
Normal distribution, 209
NOS (Eating Disorder Not Otherwise
Specified), 156
NPV (negative predictive value), 200, 201f
NREM (nonrapid eye movement), 43–45
Null hypothesis (H0), 212
Nursing homes, 194
O
Observational learning, 39
Observational study, 202
Obsessive-compulsive disorder (OCD),
28, 103, 105–106, 132
Obsessive-compulsive personality disorder
(OCPD), 28, 103, 106, 132
Obstructive sleep apnea (OSA), 46–47
OCD. See Obsessive-compulsive disorder
OCPD. See Obsessive-compulsive
personality disorder
Odds ratio (OR), 206
Open-ended questions, 179
Operant conditioning, 35, 37–39
Opiates, 146
Opioid receptors
location, 145
types, 145
Opioids
agonists, 145–146
antagonists, 145
endogenous, 82
opiates v., 146
223
Oppositional defiant disorder, 161
OR (odds ratio), 206
Oral phase, 4
Ordinal data, 214
Orgasmic disorder, 52
OSA (obstructive sleep apnea), 46–47
Osteoporosis, 17
Overdose, narcotic, 147
Oxycodone, 146
Oxytocin, 82
P
p (probability) value, 213
Palliative care, 186, 194
Palmar grasp, 6
Panic disorder, 103–105
Papaverine, 53
Parachute reflex, 6
Paranoid personality disorder, 29, 126–127
Paranoid schizophrenia, 89
Paraphilias, 54
Parasomnias, 45
Parietal lobe lesion, 76
Parkinson’s disease, 78–79
Parotiditis, 155
Paroxetine, 95t, 167–168
Passive suicidal ideation, 67
Patient adherence, 179
Patient autonomy, 181
Patient confidentiality, 178, 187–188
Patient referrals. See Referrals, patient
Pavlov’s classical conditioning, 36, 36f
Paxil. See Paroxetine
Pedigree study, 69
Pedophilia, 54
Pentazocine, 146
Peripheral nervous system (PNS), 75–76
Personality disorders, 66, 125–133
classification, 125–126
cluster A, 126–127
cluster B, 127–128
cluster C, 130–131
definition, 125
psychosis and, 86
Pervasive development disorders, 159–161
Asperger disorder, 159–160
autistic disorder, 159–160
childhood disintegrative disorder, 159, 161
Rett disorder, 159–160
Phallic phase, 4
Phencyclidine, 144. See also Substance abuse
Phentolamine, 53
Phobias, 37
Physician impairment, 182
Piaget, Jean, 3–5
PNS (peripheral nervous system), 75–76
224
“Pooled-risk,” 192
Positive predictive value (PPV),
200, 201f
Positive reinforcement, 37–38
Postpartum “blues,” 15–16
Postpartum major depression, 16, 94
Postpartum psychosis, 16
Posttraumatic stress disorder (PTSD),
62, 103, 107–108
adjustment disorder v., 108
ASD v., 108
suicide and, 66
Power, 212–213
Power of attorney, 184
PPOs (preferred provider organizations),
193
PPV (positive predictive value), 200, 201f
Prazosin, 108
Precision, 204
Preferred provider organizations (PPOs),
193
Pregnancy and childbirth
benzodiazepines during, 165
bipolar disorder and, pharmacologic
treatment, 173
postpartum period, 15–16
“blues,” 15–16
major depression, 16
psychosis, 16
Premature birth, 5
Premature ejaculation, 52
Prevalence, 199
Priapism, 168
Primary process thinking, 26
Principle of double-effect, 181
Probability (p) value, 213
Progesterone, 51
Projection, as defense mechanism,
27, 29
Prospective study, 201
Prozac. See Fluoxetine
Psychiatric disorders, 69–71. See also Major
depressive disorder; Psychosis;
Schizophrenia
Psychoanalytic theory, 25–33
defense mechanisms, 26–30, 31–32t
psychotherapy, 26–27
structural theory of the mind, 25
topographic theory of the mind, 25
Psychosis, 85–86
clinical hallmarks, 85
hallucinations, 85–86
from medical conditions, 86
narcolepsy and, 86
personality disorders and, 86
from pharmacological agents, 171
postpartum, 16
Index
Psychotherapy, 26–27
for major depressive disorder, 98–99
psychodynamic, 26–27
for specific phobia, 109
Psychotic disorders, 85–92
PTSD. See Posttraumatic stress disorder
Punishment, 37–38
Purging, 155
Q
Quaternary amines, 78
R
r (correlation coefficient), 211
Rape, 61–62
Rapid eye movement (REM), 20, 43–45
Rapport, 177
Ratio data, 214
Rationalization, as defense mechanism,
27–28
Reaction formation, as defense mechanism,
27–28
Referrals, patient, 177
Refusal of treatment
by patients, 186
by physicians, 187
Regression, as defense mechanism, 27, 29
Reinforcement, in operant conditioning,
37–39
Relapse, 142, 150
Relative risk (RR), 205–206, 205f
Reliability, 204
REM (rapid eye movement), 20, 43–45
Remeron. See Mirtazapine
Repression, as defense mechanism, 27, 29
Research study designs, 201–203
Reserpine, 94
Reticular system lesion, 76
Retrospective study, 202
Rett disorder, 159–160
Risperidone, 172
Ritalin, 46
Rivastigmine, 114
Romazicon. See Flumazenil
Rooting reflex, 6
RR (relative risk), 205–206, 205f
S
Schizoaffective disorder, 86, 91
Schizoid personality disorder, 126, 130–131
Schizophrenia, 69–70, 87–91
abnormal thought formation, 88
antipsychotics for, 90
catalepsy, 90
catatonic, 89
characteristic symptoms, 87–88
disorganized speech, 87
Index
Schizophrenia (Cont.):
dopamine hypothesis, 89
dopamines for, 78
downward drift, 89
EPS, 90–91
gender and, 69, 89
genetic factors, 69–70
among monozygotic twins, 70
paranoid, 89
prevalence, 69
prodromal phase, 88
prognosis, 90
residual phase, 88
schizotypal personality disorder and, 127
subtypes, 89
suicide and, 66, 90
TD, 90–91
waxy flexibility, 90
Schizophreniform disorder, 86
Schizotypal personality disorder, 29, 71, 127
Selective mutism, 163
Selective serotonin reuptake inhibitors (SSRIs)
for children, 167
commonly used, 167
for depression, 94, 95t, 167
for GAD, 104
MAOIs and, 98
for panic disorder, 105
side effects, 167
for suicide, 67
Sensitivity, 200
Sensitization, 41
Separation anxiety disorder, 163
Serotonin, 79–80
altered behavioral factors, 79–80
as biogenic amine, 79–80
decreased aggression and, 63
depression, 47
in sleep, 44
synthesis, 80
Serotonin syndrome, 98
Sertraline, 95t, 167
Serzone. See Nefazodone
Sexual abuse, 58–59
Sexual assault, 61–62
Sexual aversion disorder, 53
Sexual consent, 61
Sexual development, 49–51
Sexual masochism, 54
Sexual response, 51–56
drugs as influence on, 55–56
dysfunction, 52–53
medical conditions and, 54–55
normal cycle, 51–52
paraphilias, 54
serotonin and, 80
225
Sexual sadism, 54
Sexual violence, 61–62
Sexuality, Tanner stages of development for,
12, 13t
Shaken baby syndrome, 58
Shaping, 38
Shared psychotic disorder, 91
SIG E CAPS, 93
Sildenafil citrate, 53
Sleep, 43–48
abnormal, 45–47
Alzheimer’s disease, 48
depression, 47–48
disorders, 45–47
normal, 43–45
patterns among elderly, 20
Sleep terrors, 47
Sleepwalking, 47
Social phobia, 103, 106–107, 109
Somatization disorder, 71, 118–119
Somatoform disorders, 117–124
body dysmorphic disorder, 106, 121
conversion disorder, 117t, 119–120
factitious disorder, 117, 117t, 122–123
hypochondriasis, 120
malingering, 117, 117t, 123
primary types, 117, 117t
somatization disorder, 71, 118–119
Somatostatin, 82
Specific phobia, 103, 108–109
Specificity, 200
Splitting, as defense mechanism, 27–29, 128
Spontaneous recovery, 37
Spooning, 58
SSRIs. See Selective serotonin reuptake
inhibitors
Standard deviation, 211–212, 211f
Stanford-Binet scale, 41
“Startle reflex.” See Moro reflex
Statistics
distribution, 209–212, 210f
hypothesis and error types, 212–214
tests, 214–215
Statutory rape, 62
Stepping reflex, 6
Steroid use, 63, 94
Stimulus generalization, 37
Structural mind theory, 25
Sublimation, as defense mechanism, 27–28
Substance abuse, 139–151
aggression and, 63
cravings, 142
delirium and, 111
dissociative disorders, 135
among elderly, 21
Himmelsbach hypothesis, 140
226
Substance abuse (Cont.):
medical effects, 143
mood disorders and, 86
nonmedical effects, 144
physiological pathways, 140
relapse, 142
sexual assault and, 61
sexual response and, 55–56
suicide, 66
tolerance and, 139
treatment, 139–142
detoxification, 142
negative reinforcement, 142
positive reinforcement reduction, 141
principles, 140
substitute drugs, 141
symptom prevention, 140
withdrawal, 139–142
Substance P, 82
Suicide, 65–68
antidepressants, 67
depression and, 67
gender and, 65
ideation, 67
major depressive disorder and, 93
MAOIs in treatment therapy, 67
PTSD, 66
race and, 66
risk factors, 65–66
schizophrenia, 66
substance abuse, 66
Superego, 26
Suppression, as defense mechanism, 29
Systematic desensitization, 40
T
Tacrine, 81
Tanner stages of development, 12, 13t
Tardive dyskinesia (TD), 90–91
TCAs. See Tricyclic antidepressants
TD (tardive dyskinesia), 90–91
Tegretol. See Carbamazepine
Temporal lobe lesion, 76
Testing, 203–204
Testosterone, 51
Test-retest reliability, 204
Thiamine deficiency, 115
Thought blocking, 88
Tolerance, 139, 149. See also Substance abuse
Topographic mind theory, 25
Index
Tourette disorder, 72, 162–163
Transference, 30
Transvestic fetishism, 54
Trazodone, 96t, 168
Trichotillomania, 106
Tricyclic antidepressants (TCAs), 80, 97–98,
169–170
commonly used, 98, 169
mechanism of action, 168–169
overdose, 169
side effects, 97, 169
tertiary, 169
t-test, 214–215
Turner syndrome, 51
Twins. See Dizygotic twins; Monozygotic
twins
Type I (α) error, 212
Type II (β) error, 212
U
Uprima. See Apomorphine
V
Valproic acid, 100t, 173
Vanillylmandelic acid (VMA), 79
Variable ratio reinforcement, 39
Variables, 210
Vascular dementia, 113
Vasoactive intestinal peptide (VIP), 82
Vasopressin, 82
Venlafaxine, 97t, 104
Viagra. See Sildenafil citrate
VIP (vasoactive intestinal peptide), 82
VMA (vanillylmandelic acid), 79
Voyeurism, 54
W
Waxy flexibility, 90
Wellbutrin. See Bupropion
Wilcoxon test, 215
Withdrawal. See also Substance abuse
from alcohol, 141, 143
from benzodiazepines, 166
from drugs, 141–142
Word salad, 88
Z
Zero-order elimination, of drugs,
148, 148f
Zoloft. See Sertraline

Deja Review Behavioral Science, Second Edition

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