Olle Jane Z. Sahler · John E. Carr (Editors) - Hogrefe Publishing

Olle Jane Z. Sahler · John E. Carr (Editors)BehavioralTheSciences andHealth Care3rd edition

The Behavioral Sciences and Health Care

Praise for This Edition“At a time when every major report on the future of health care calls for a broad perspective and greater teamwork,it is refreshing to see a major textbook propose, as well as extensively document, an ‘integrated sciences model’ foruniting the contributions of the biomedical and the behavioral sciences in teaching and practice. This text should berequired reading for all health sciences students and their faculties, as we move toward a system of truly collaborative,interprofessional health care delivery.”DeWitt C. Baldwin, Jr., MD, Professor emeritus of Psychiatry and Behavioral Sciences, University of NevadaSchool of Medicine, Reno, NV“The person, the patient, must be the focus of health care, not the system or the profession. This outstanding book byO.J. Sahler, MD, and Jack Carr, PhD, and its integrated sciences model go a long way towards making this a reality.It is more than a standard text for medical students – it should also be required reading for students of pharmacy,nursing, social work, psychology, and sociology and their attendings – as well as for health care administratorsand politicians.”Albert H. Eaton, Ph.D., MDiv, President of the Association for the Behavioral Sciences and Medical Education(ABSAME)“An outstanding integration of the most up-to-date scientific knowledge gathered across disciplines, targeted forclinicians. Understandable, timely; straightforward yet pleasantly sophisticated. A wonderful desk reference for primarycare providers.”Pat DeLeon, PhD, MPH, JD, former President of the American Psychological Association“This is a wonderful volume incorporating information normally found in separate textbooks for psychiatry residents,graduate students in clinical psychology, health psychology, social work and public health. Rarely would thisinformation be gathered into one volume and integrated into a model that seriously considers biology and psychology.The book is especially timely as efforts at health care reform have emphasized an integrated model of medicinethat takes into account genes, environment and their interactive processes. The book provides a reasoned rationalefor these efforts. As advances in health and illness are made, it becomes obvious to clinicians and researchers that theboundaries between biology and psychology are less clear and more fluid. The book is comprehensive, dealing withhistorical topics such as Freud’s psychoanalytic theory as well as contemporary topics such as the brain networksdiscussed by Michael Posner, a leading neuroscientist. Traditional psychopathology is presented as well as currentconcerns about social and cultural effects on health/illness. The book will do much to initiate the life -long educationof health professionals about these issues or as a primer for these who are new or less familiar with the interplay ofbehavior and health.”Barry A. Hong, PHD, ABPP, Professor of Psychiatry and Medicine at the Washington University, St. Louis, MO“The publication of the new edition of The Behavioral Sciences and Health Care could not come at a better time. Itseditors, Drs. Olle Jane Z. Sahler and John E. Carr, are two superb senior scholars who have updated their volume justas the American Association of Medical Colleges has declared that physicians must be better prepared in the behavioralsciences if they are to understand a myriad of health problems they now must treat. The talented group of chapterauthors and the breadth covered in this volume make it necessary reading for all medical students. Its readabilityand currency also make it a fine preparation for students about to take the Medical College Admissions Test, whichhas added a new emphasis on the behavioral sciences. This volume has no peer in educating aspiring physiciansin how a biopsychosocial understanding of medicine’s challenges is the only approach a thoroughly prepared medicalpractitioner can take.”Edward P. Sheridan, PhD, LHD, ABPP, former Chief of Psychiatry Outpatient Services and Professor andChairman of the Division of Psychology at Northwestern University Medical School. Currently, he is UniversityProfessor and Senior Vice President and Provost Emeritus at the University of Houston.“This textbook provides a comprehensive overview of health care that can be a valuable resource for any clinicianworking in a medical setting. It offers a well-rounded view of the various aspects of the biopsychosocial model thathelps to integrate theory into practice. As a music therapist, it gives insight into how the medical field works from abehavioral approach, which is very much in line with the Medical Music Therapy perspective. I plan to use it with allinterns as part of their orientation process for working in the medical setting.”Rosemary Oliva Obi, MS, LCAT, MT-BC, Music Therapist at the University of Rochester Medical Center GolisanoChildren’s Hospital, Rochester, NY

The Behavioral Sciencesand Health Care3rd EditionEditorsOlle Jane Z. Sahler, MDProfessor of Pediatrics, Psychiatry, Medical Humanities, and Oncology at theUniversity of Rochester School of Medicine and Dentistry, Rochester, NYJohn E. Carr, PhDProfessor emeritus of Psychiatry & Behavioral Sciences and Psychology at theUniversity of Washington School of Medicine, Seattle, WAAssociate EditorsJulia B. Frank, MDAssociate Professor of Psychiatry and Behavioral Sciences at the George WashingtonUniversity School of Medicine and Health Sciences, Washington, DCJoão Vieira Nunes, MDAssociate Medical Professor of Physiology and Pharmacology at the Sophie DavisSchool of Biomedical Education at The City College of New York, NY

Library of Congress Cataloging-in-Publication Datais available via the Library of Congress Marc Database under theLibrary of Congress Control Number: 2012931374Library and Archives Canada Cataloguing in PublicationThe behavioral sciences and health care / editors, Olle Jane Z. Sahler, John E. Carr ;associate editors, Julia B. Frank, João Vieira Nunes. -- 3rd ed.Includes bibliographical references and index.ISBN 978-0-88937-433-11. Medicine and psychology--Textbooks. 2. Social medicine--Textbooks. 3. Psychology,Pathological--Textbooks. I. Sahler, Olle Jane Z., 1944- II. Carr, John E III. Frank, Julia (Julia B.)IV. Nunes, João VieiraR726.5.B452 2012 616.001’9 C2012-900649-1© 2012 by Hogrefe PublishingPUBLISHING OFFICESUSA: Hogrefe Publishing, 875 Massachusetts Avenue, 7th Floor, Cambridge, MA 02139Phone (866) 823-4726, Fax (617) 354-6875; E-mail customerservice@hogrefe-publishing.comEUROPE: Hogrefe Publishing, Merkelstr. 3, 37085 Göttingen, GermanyPhone +49 551 99950-0, Fax +49 551 99950-425, E-mail publishing@hogrefe.comSALES & DISTRIBUTIONUSA:Hogrefe Publishing, Customer Services Department,30 Amberwood Parkway, Ashland, OH 44805Phone (800) 228-3749, Fax (419) 281-6883, E-mail customerservice@hogrefe.comEUROPE: Hogrefe Publishing, Merkelstr. 3, 37085 Göttingen, GermanyPhone +49 551 99950-0, Fax +49 551 99950-425, E-mail publishing@hogrefe.comOTHER OFFICESCANADA: Hogrefe Publishing, 660 Eglinton Ave. East, Suite 119-514, Toronto, Ontario, M4G 2K2SWITZERLAND: Hogrefe Publishing, Länggass-Strasse 76, CH-3000 Bern 9Hogrefe PublishingIncorporated and registered in the Commonwealth of Massachusetts, USA, and in Göttingen, Lower Saxony,GermanyNo part of this book may be reproduced, stored in a retrieval system or transmitted, in any form or by any means,electronic, mechanical, photocopying, microfilming, recording or otherwise, without written permission from thepublisher.Printed and bound in the USAISBN 978-0-88937-433-1

About the EditorsOlle Jane Z. Sahler, MD, Co-Editor, is Professorof Pediatrics, Psychiatry, Medical Humanities,and Oncology at the University of RochesterSchool of Medicine and Dentistry. She is a behavioralpediatrician with a special interest in thecare of chronically and terminally ill childrenand their families, and in the treatment of childrenand adolescents with chronic pain syndromesusing an integrative medicine approach. She haswritten widely on medical student, resident, andpractitioner education in the areas of child development,management of behavioral problems athome and school, and palliative care, end-of-lifecare, and bereavement counseling. Her foundationand National Cancer Institute funded multiinstitutionalresearch over 25 years has focused onsiblings and mothers of children with cancer. Shehas also been funded by the National Center forComplementary and Alternative Medicine of theNational Institutes of Health to study the effectsof using music therapy on symptom control andimmune reconstitution in the management ofpatients undergoing stem cell transplantation.As an educator, she was the Director of thePediatric Clerkship at the University of RochesterSchool of Medicine for 17 years and the Directorof the Department of Education at the AmericanAcademy of Pediatrics in 1995–1996. Shewas the founding chairperson of the MedicalStudent Education Special Interest Group of theAcademic Pediatric Association (formerly, theAmbulatory Pediatric Association) and foundingpresident of the Council on Medical StudentEducation in Pediatrics (COMSEP). As Presidentof the Association for the Behavioral Sciences andMedical Education (ABSAME) in 1992–1993,she began a project to develop a comprehensivecurriculum guide for medical student and residenteducation in the behavioral sciences that waspublished in 1995. An updated version of this curriculumguide, reflecting the many advances in thebehavioral sciences that occurred around the turnof the century, forms the foundation for this book,now in this third edition. The authors and editorswho contributed to this text represent the diverseexperience and expertise of ABSAME’s membership,working in conjunction with other expertprofessionals dedicated to excellence in education.A graduate of Radcliffe College/HarvardUniversity, Dr. Sahler received her MD degreewith distinction in research at the University ofRochester, was a resident in Pediatrics at theDuke University Medical Center, and completeda fellowship in Behavioral and DevelopmentalPediatrics/Child and Adolescent Psychiatry at theUniversity of Rochester. She served as a Captainin the U.S. Army Medical Corps and received aSpecial Commendation Award for her work inchild abuse in the military.John E. Carr, PhD, Co-Editor, is Professoremeritus of Psychiatry & Behavioral Sciencesand Psychology at the University of Washingtonwhere he served a four year term as Acting Chairof the Department of Psychiatry & BehavioralSciences, was Director of Undergraduate MedicalEducation, and played a principal role in developingbehavioral science curricula for the Schoolof Medicine. He has written extensively aboutthe need for an “Integrated Sciences Model” forthe behavioral and biological sciences in medicaleducation and clinical psychology graduate training.He has served as a consultant to the WorldHealth Organization on Behavioral Sciences inHealth Care Training, and co-coordinated a cooperativeventure between the Association for theBehavioral Sciences and Medical Education, theAssociation of Medical School Psychologists, andthe International Union of Psychological Societiesin developing behavioral science training modulesfor WHO.Dr. Carr received an MA in IndustrialPsychology and a PhD in Clinical Psychologyfrom Syracuse University. He is a Diplomate inHealth Psychology of the American Board ofProfessional Psychology. He is a Fellow of theAmerican Psychological Association, Associationof Psychological Science, Society of BehavioralMedicine, and the Academy of BehavioralMedicine Research. He has served on the NationalBoard of Medical Examiners Behavioral SciencesTest Committee, and is a founding member

viand was twice elected to the Presidency of theAssociation of Psychologists in Academic HealthCenters. His promotion of an integrated sciencesmodel in medical education and graduate psychologytraining reflects his bio-behavioral orientationand a career-long research program focused uponidentifying the mechanisms of bio-behavioralinteraction in stress, anxiety, and depression.He is the recipient of a Distinguished EducatorAward from the Association of Psychologistsin Academic Health Centers, the Gary TuckerAward for Lifetime Achievement in Teaching andDedication to Education from the Departmentof Psychiatry of the University of Washington,and Distinguished Psychologist Awards forContribution in Scholarship and for Contributionto the Field of Psychology from the WashingtonState Psychological Association.Julia B. Frank, MD, Associate Editor, is AssociateProfessor of Psychiatry and Behavioral Sciencesand is the Director of Medical Student Educationin Psychiatry and Director of the PsychiatryClerkship at the George Washington UniversitySchool of Medicine and Health Sciences. Herresponsibilities include organizing the pre-clinicalbehavioral sciences curriculum and integratingit with the psychiatry clerkship. As a graduateof the GWU Master Teachers Program, she hasdeveloped an interest in multiple modes of studentlearning, including team based learned, problembased learning, medical readers theater, medicalhumanities, and self-directed learning. She coauthoreda question/review book for NBME StepOne, which became the foundation of many of thereview questions in the second and third editionsof The Behavioral Sciences and Health Care. Shebecame co-editor of the third edition specificallyto help align it with current thinking about the roleof evolutionary processes in pathology in generaland psychopathology in particular.Dr. Frank is a member of the Society ofDistinguished Teachers, a former board memberof the Association for Behavioral Sciences andMedical Education, a Diplomate of the AmericanBoard of Psychiatry and Neurology, and aDistinguished Fellow of the American PsychiatricAssociation. She was named Psychiatrist of theYear by the Washington Psychiatric Society in2005, based on organizing colleagues to work withsurvivors of Hurricane Katrina. Her other scholarlywriting includes co-authorship with her father,The Behavioral Sciences and Health CareJerome D. Frank, MD, PhD, of Persuasion andHealing: A Comparative Study of Psychotherapy(1991), a classic work explaining the universal processesand effects of psychotherapy, written especiallyfor medical students and trainees in othermental health disciplines. More recently, she coedited,with Renato Alarcón, The Psychotherapyof Hope: The Legacy of Persuasion and Healing(Baltimore: Johns Hopkins Press; 2012). Otherscholarly interests include research into the pharmacologicaltreatment of post-traumatic stress disorderand writing about women’s mental health,victims of violence, and various topics in the historyof medicine. She has also published medicalcomic poetry in the New England Journal ofMedicine.A graduate of Yale University School ofMedicine, the internal medicine internship ofthe Michael Reese Hospital in Chicago, and thepsychiatry residency of the Yale Department ofPsychiatry, Dr. Frank has provided clinical psychiatriccare to chronically mentally ill veterans,medically ill patients, university students, and refugeesseeking asylum. Her current practice servesoutpatients with anxiety, mood disorders, perinatalpsychiatric syndromes, and a wide range of otheradaptive disorders.João Vieira Nunes, MD, Associate Editor, isAssociate Medical Professor of Physiology andPharmacology at the Sophie Davis School ofBiomedical Education at The City College ofNew York, City University of New York. He hasbeen instrumental in developing behavioral science,neuropsychiatry, and doctoring curricula atSophie Davis. He is a Diplomate of the AmericanBoard of Psychiatry and Neurology, a psychiatristand child and adolescent psychiatrist with aspecial interest in brain and behavior, childhooddevelopment and psychopathology, health disparitiesrelated to sleep disorders and chronobiology,and personal narratives for the understandingof food-related behaviors. He has written widelyon medical student education, on sleep disordersand chronobiology, and health disparities. He hasdedicated much of his career to providing medicalcare in underserved areas of The Bronx andHarlem in New York City (where he still practices),to the cause of facilitating access of under-representedminorities to medical education, and toundergraduate and graduate medical education ascourse director currently, and, in the past, as psy-

About the Editorsviichiatry clerkship and residency program director.He directs or co-directs three required courses inundergraduate medical education.As a member and former board member ofthe Association for the Behavioral Sciences andMedical Education, he played an important rolein the development of the Behavioral ScienceCurriculum Guide published in 1995 to provide aneducational template in the behavioral sciences formedical students and residents and their teachers.Beyond the medical field, he composes and performsmusic and writes poetry, having recently published,with two other poets, a bilingual (English/Portuguese) anthology titled True Word.A graduate of the Faculty of Medicine ofEspirito Santo Federal University, Brazil, he completedresidencies in Pediatrics, Psychiatry, andChild Psychiatry at the Rio de Janeiro FederalUniversity. After moving to New York, he completedresidency and fellowship training inPsychiatry and Child and Adolescent Psychiatryat Albert Einstein College of Medicine, and hasattended the Harvard-Macy Institute for PhysicianEducators.

Preface to the Third EditionIn prior editions, we stressed the critical importanceof combining the principles of the behavioralsciences with those of the biological sciences todevelop a comprehensive understanding of healthand illness. This concept of an integrated sciencesmodel of research, clinical training, and healthcare delivery anticipated an explosion of interdisciplinarystudies focused on the mechanisms bywhich biological and behavioral factors interact toinfluence health outcomes. Simultaneously, therehas been increasing recognition that transdisciplinarycollaboration among health care professionalsis essential if we are to create unified, efficacious,and cost effective delivery systems.Our objectives in this new edition are twofold:(1) to amplify our understanding of the mechanismsand processes contributing to bio-behavioralinteractions by reviewing recent researchadvances from behavioral genomics, cognitiveand social neurosciences, psychoneuroendocrinology,and other interdisciplinary research fieldsrelevant to health care; and (2) to examine howtransdisciplinary practice can promote the broaderapplication of knowledge gained from integratingthe biological and behavioral sciences in the trainingof all health care professionals.The Association for the Behavioral Sciencesand Medical Education (ABSAME) gave rise tothis textbook through the development of a setof educational guidelines for the behavioral sciences,and has supported its evolution over thepast decade. This year, ABSAME is in the processof changing its name to the Association forthe Behavioral Sciences and Health ProfessionsEducation. This shift in focus and membershipreflects a growing understanding that it is onlythrough transdisciplinary efforts that we can keepthe world’s population as free of disease as possibleand maximize the sense of self-efficacy andwell-being that is essential to living a full and productivelife.There are limits to the resources that professionalscan rely on to improve and maintain thehealth of society. It is clear that the expertise ofmany different disciplines and the accountabilityof all members of the team are crucial elementsof an efficient, effective health care system. Thus,it is incumbent on all of us to integrate scientificknowledge and apply our respective skills cooperativelytoward achieving our mutual goals.In keeping with these objectives, this text isdesigned to provide an understanding of howthe behavioral and biological sciences interact toinfluence health care. It is also designed to provideinformation and insight from the behavioral sciencesthat can be applied to the clinical practice ofany health care provider regardless of discipline.In the section on the Clinical Encounter, we usethe physician-patient relationship as an exampleof the broader clinician-client relationship that isthe backbone of health care. However, the professionalresponsibility to provide information, teach,advise, guide decision making, and advocate forthe best interests of the person seeking our counsel,all with the utmost integrity, is inherent in thestandards of all provider groups. We hope that theuniversal role the behavioral sciences play in optimizingwell-being will be self-evident and thatyou will find these principles applicable in everyhealth care encounter.The Editors

Table of ContentsAbout the Editors. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vPreface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ixAcknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xTable of Contents. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xiSection I The Behavioral Sciences and Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1Introduction and How to Use this Book . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31 Evolving Models of Health Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5Section II Brain Systems. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 132 Predisposition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 153 The Nervous System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 224 Brain Networks in Health and Illness. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31Section III Homeostatic Systems and Disorders. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 375 Nutrition, Metabolism, and Feeding Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . 396 Chronobiology and Sleep Disorders. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 447 Stress, Adaptation, and Stress Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52Section IV Individual-Environment Interaction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 638 Emotion and Learning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 659 Cognition and Social Interaction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74Section V Development Through the Life Cycle . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8310 Selected Theories of Development . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8511 The Fetus, Newborn, and Infant. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9212 Toddlerhood and the Preschool Years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9813 The School Years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10414 The Adult Years . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11215 The Family . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121Section VI Social and Cultural Issues. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13116 Social Behavior and Groups. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13317 Theories of Social Relations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13918 Culture and Ethnicity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14619 Health Care in Minority and Majority Populations . . . . . . . . . . . . . . . . . . . . . . . 15520 Sexuality and Sexual Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16221 Health Care Issues Facing Gay, Lesbian, Bisexual, and Transgender Individuals. . 17322 Geriatric Health and Successful Aging . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 181

xiiThe Behavioral Sciences and Health CareSection VII Societal and Behavioral Health Challenges . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19123 Obesity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19324 Eating Disorders. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19925 Substance Abuse. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20626 Interpersonal Violence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21227 Poverty and Homelessness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22028 Suicide . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22729 Health Literacy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 235Section VIII The Health Care System, Policy, and Economics . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24130 The U.S. Health Care System. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24331 Complementary and Integrative Medicine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25432 Palliative Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26433 Ethical and Legal Issues in Patient Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 274Section IX The Clinical Relationship . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28334 The Physician-Patient Relationship . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28535 The Medical Encounter and Clinical Decision Making . . . . . . . . . . . . . . . . . . . . 29236 Motivating Healthy Behavior. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30137 Physician Health, Impairment, and Misconduct . . . . . . . . . . . . . . . . . . . . . . . . . 308Section X Psychopathology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31538 Introduction to Psychopathology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31739 The Psychiatric Evaluation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32240 Principles of Psychotherapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32941 Pharmacological Interventions for Psychiatric Disorders . . . . . . . . . . . . . . . . . . 33542 Somatization and Somatoform Disorders. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34343 Adjustment Disorders, Bereavement, and Demoralization . . . . . . . . . . . . . . . . . 34844 Dementia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35245 Delirium and Secondary Syndromes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35946 Anxiety and Dissociative Disorders. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36547 Major Mood Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37348 Schizophrenia and Other Psychotic Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . 38149 Personality and Impulse Control Disorders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38850 Disorders of Infancy, Childhood, and Adolescence . . . . . . . . . . . . . . . . . . . . . . 396AppendicesAppendix A Epidemiology. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 409Appendix B Biostatistics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 416Review Questions – Answer Key. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 407Practice ExamQuestions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 425Answers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 475Contributors. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 525Subject Index. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 531

Section IThe Behavioral Sciencesand Health

Introduction and How to Usethis BookIn the course of human experience, people areborn, mature, feel emotion, develop relationships,produce and reproduce, and struggle to cope with amyriad challenges to their survival and well-being.This book is about the diverse ways in whichhealth can be compromised; the many factors thatcontribute to an individual’s predisposition, vulnerability,and resilience; the wide range of precipitatingevents that can trigger a disease, injury, ormalfunction; and the complex array of individualdifferences that determine each patient’s uniqueresponse to a disease as well as its treatment.When health and well-being are challenged,humans have, for millennia, sought the aid of healers,individuals who are purported to possess specialknowledge about the etiology and treatment ofvarious disorders. History has witnessed the evolutionof health care from a spiritually based healingart to a scientifically based technical profession,reflecting advances in our knowledge of thebiological functioning of the human body. AfterWorld War II, there was a gradual shift away frommedicine’s exclusive focus on linear causal relationshipsbetween a disease and its biological etiology.Physicians began to refer to a “biopsychosocialmodel,” which proposed that psychosocialvariables were as important as biological variablesin determining health status.Although a major step forward in understandingthat complex interactions exist, the biopsychosocialmodel failed to explain how psychosocialvariables actually interact with biological variables.That is, what are the specific connectionsthat exist among the biological (e.g., neurotransmittersystems), psychological (e.g., emotionalreactions to stress or memory), and social (culturalprescriptions and proscriptions about appropriatephysical and interpersonal responses) factors thatdefine health and illness, and by what mechanismsare they established and maintained? In the finaldecades of the 20th century, medical researchersbegan to explore the knowledge and methodologyof psychology, sociology, anthropology, and othersocial and behavioral sciences as they apply specificallyto medicine. Focusing on bio-behavioralconnections, their studies have given rise to newfields such as behavioral genetics, behavioralneuroscience, psychoneuroendocrinology, behavioralpharmacology, social biology, and behavioralmedicine.The model presented in this book calls attentionto the clinical significance of the interactionamong biopsychosocial variables, and focuses ingreater detail on identifying the mechanisms thatinterconnect these variables. We call this extensionof the biopsychosocial model the “integratedsciences model” (ISM) because it focuses on demonstratingthe interdependence of the contributionsmade by all of the sciences basic to medicine.In Section I, we briefly trace the evolution ofhealth care practices and models, the developmentof contemporary health provider practice, andthe integrated sciences model. In Section II, wepresent a brief review of the human nervous systemand how its evolution has contributed to theunique survival capabilities of Homo sapiens. InSection III, we discuss the basic homeostatic systemsand the critically important role that the stressresponse plays in human adaptation. In Section IV,we review basic psychological principles and thebio-behavioral mechanisms involved in sensation,learning, cognition, emotion, and social interactionand cooperation. In Section V, we reviewhuman development through the life cycle andimportant aspects of major developmental theoriesas they apply to the individual and to the family.In Section VI, we examine social behavior andgroups, and the influence of culture, ethnicity,and other social factors on health and health care.In Section VII, we explore several contemporarysocial issues that contribute to, complicate, or aremajor problems in health care.In Section VIII, we examine the organizationand functioning of the health care system, the rolethat certain areas of special focus such as palliativecare play, the rise of complementary and

4 The Behavioral Sciences and Health Carealternative medicine (now integrative medicine),and some of the ethical and legal implicationsfor patients as well as health care providers. InSection IX, we discuss the clinical encounter andexamine the relevance of basic, clinical, and socialscience to understanding the patient’s complaints,eliciting and interpreting findings, making a diagnosis,negotiating a treatment plan, and motivatingpatient behavior. We also explore the importanceof patients’ health literacy and provider impairmentin effecting health outcomes. In Section X,we summarize the field of psychopathology, presentbrief descriptions of the more common psychiatricdisorders, and show how basic behavioralscience principles help us to understand this complexarea of health care.Each chapter in this volume begins with a setof bulleted questions designed to focus your attentionon key learning points. Each chapter alsoconcludes with a short set of review questionsbased on information in the text. We have chosento emphasize ideas, principles, and establishedresearch findings, and to minimize references infavor of providing selected recommended readings.Finally, significant scientific observationsfrom the behavioral sciences as well as clinicalapplications and examples have been included tomake the theoretical practical.In the Appendices, we have presented the elementsof epidemiology and biostatistics that areessential to understanding and interpreting bothmedical and behavioral science data. Lastly, wehave included more than 350 multiple-choicequestions with explanations of the correct answerand why the incorrect choices are, in fact, incorrect.Some of the questions in this section provideadditional review of material in the text. However,many questions are focused on new material tomake the contents of the book even more comprehensivethrough the use of brief, directed discussions.The construction of these questions isdesigned to give you a sense of the kind of materialand question format you may encounter laterin training.Good medicine is science artfully applied.The laws of probability should be interpreted inthe light of experience and intuition, and commonsense appreciated as a useful guide to decisionmaking. Respect for the autonomy and selfefficacyof the patient will usually lead to the bestoutcome – although not everyone may agree withwhat the patient wants as the outcome.We have tried to be explicit in defining themechanisms of bio-behavioral interaction wherethey are known and to incorporate typical patientexperiences where relevant. Some of the materialwill seem self-evident, some will seem counterintuitive,but all derives from the amalgam ofresearch findings from the biological, behavioral,cognitive, sociocultural, and environmental sciencesthat contribute to our knowledge of thedeterminants of health and illness important foryou as well as your patients.Olle Jane Z. Sahler, MDJohn E. Carr, PhDJulia B. Frank, MDJoao V. Nunes, MD

23 ObesityKristin A. Evans, MS, and Stephen R. Cook, MD, MPH• How is obesity defined?• What health consequences can result from obesity?• How do individual and environmental factors interact to cause obesity?• What can be done to reverse the current obesity epidemic?The current national obesity epidemic is likelybeing driven by a combination of genetic and psychosocialfactors occurring in an environment rifewith calorie-dense/nutrient-poor foods. Efforts toreverse the trends in overweight and obesity inthe US must include interventions at many levels,ranging from individual behavior modification tonational policy changes.What is Obesity?How is obesity defined?Simply defined, obesity refers to an excess accumulationof body fat that results in a body massexceeding a recommended level. An individual’sweight status is generally quantified by calculatingtheir body mass index (BMI), which is a ratio ofbody mass (kilograms) to height (meters squared).Adults with a BMI between 25.0 and 29.9 kg/m 2 are classified as overweight, whereas thosewith a BMI ≥ 30.0 kg/m 2 are considered obese.Adults with a BMI between 35.0 and 40.0 kg/m 2and ≥ 40.0 kg/m 2 are often referred to as severelyobese and morbidly obese, respectively.Children and adolescents are classified clinicallyas either normal weight, overweight, or obesebased on age and gender-specific growth chartsdeveloped by the Centers for Disease Control andPrevention (CDC). Children ≥ 85th but < 95thBMI percentile for their age and gender are classi-fied as overweight and those ≥ 95th percentile areconsidered obese.The EpidemicAccording to the CDC’s most recent estimates,more than two thirds (68.3%) of the U.S. adultpopulation (≥ 20 y.o.) is overweight or obese, withabout one third of those (33.9%) falling into theobese category. Among children and adolescents(2–19 y.o.), nearly one third (31.7%) are overweightor obese, with more than half of those (16.9%)already falling into the obese category. These datareflect a 46% increase in adult overweight/obesityprevalence in the past four decades, and a greaterthan three-fold increase in child overweight/obesityover that same time period (Figure 23.1).The proportion of Americans who are overweightand obese varies by race/ethnicity and gender.For example, a greater proportion of blacksand Hispanics are overweight or obese comparedto white Americans (73.7% and 76.9% vs. 67.5%).Prevalence of a BMI ≥ 25 kg/m 2 is 72.3% and64.1% among adult men and women, respectively,although this gender difference also varies withracial/ethnic group. Among whites, a higher percentageof men than women are overweight orobese; the opposite is true among blacks. MoreHispanic men than women are overweight orobese, but the difference is less pronounced thanamong whites, and the pattern seems to shift withincreasing age.

194 The Behavioral Sciences and Health Care40%35%30%25%20%15%10%5%0%1960–19641971–19741976–19801988–19941999–20002001–20022003–20042005–20042007–2008Children, 1–19Adults, 20–74Figure 23.1. Trends in obesity among U.S. children and adults, 1960–2008. Sources: CDC/NCHS, National HealthExamination Surveys I–III, and National Health and Nutrition Examination Surveys I–III, 1999–2000, 2001–2002,2003–2004, 2005–2006, 2007–2008.Among children (2–19 y.o.), approximately thesame proportion (31–32%) of girls and boys havea BMI ≥ 85th percentile, and the racial/ethnic differencesare similar to those seen in adults (whites29.3%, blacks 35.9%, Hispanics 38.2%).ConsequencesOver the past several decades, it has becomeincreasingly evident that overweight and obesityare much more than just aesthetic problems. Excessbody weight and fat significantly increase an individual’srisk for a number of other diseases and conditionsincluding insulin resistance, type 2 diabetes,heart disease, osteoarthritis, reproductive complications,and certain cancers including breast, uterine,colon, and kidney cancer. The risk of prematuredeath from any cause is estimated to be 50–100%greater among overweight/obese individuals comparedto those who are normal weight. For manydiseases, the relative distribution of body fat is amore significant risk factor than BMI. Individualswith excessive abdominal adiposity, as opposed tomore fat in the lower body (measured via the waistto-hipratio), are at greater risk of developing type 2diabetes or suffering a heart attack.Economically, the costs associated with obesityin the US are substantial. The most recent governmentestimates indicate that medical spendingattributable to overweight/obesity (including in/outpatient services and prescription drug costs)is nearly $150 billion per year, with a substantialportion of that being paid by government-fundedinsurance programs (Medicare, Medicaid).This total accounts for nearly 10% of all medicalexpenditures in the US.What health consequences can result from obesity?What Causes Obesity?How do individual and environmental factors interactto cause obesity?At the most fundamental level, overweight and obesityresult from an excess intake of food calories inrelation to calorie expenditure (basal metabolic rate+ physical activity). Although debated in the currentliterature, the prevailing evidence supports theidea that, on a population level, the positive energybalance associated with the high prevalence ofoverweight and obesity is due more to an increasein caloric intake than to a substantial decreasein physical activity. The following sections willdescribe the individual and social factors that influencethis energy imbalance, as well as how theseforces interact to create the population’s weight crisis.Current evidence also supports the notion thatobesity is the result of a complex interplay of genetic,environmental, and psychosocial factors.

Chapter 23: Obesity 195Genetic FactorsDetermining the precise contribution of genesto an individual’s body weight and to the obesityepidemic has proven difficult. In only the rarestcases can any single gene explain obesity in agiven individual – a phenomenon known as monogenicobesity. For the rest of the population, bodyweight and body fatness are regulated by complexgene-gene and gene-environment interactions.Estimates of the heritability of BMI and body fatrange from 16–85%, and 35–63%, respectively. Todate, more than 100 single genes have been positivelyassociated with the development of obesity;many of them are involved in the regulation ofenergy metabolism, fat deposition, and hormonesignaling. The most compelling evidence supportsa role for genes encoding peroxisome proliferatoractivatedreceptors involved in nutrient metabolism,melanocortin-4 receptors involved in feedingand metabolism, β 3-adrenergic receptors regulatinglipid metabolism and thermogenesis, anduncoupling proteins involved in oxidative phosphorylation.Genes associated with neurotransmitteraction have also been linked to food intake andbody weight/BMI (see Chapter 5, Nutrition,Metabolism, and Feeding Disorders). It has beenpropo,sed that for some obese people eating is aResearch has shown that physicians and medical studentswho themselves engage in regular physical activityare more successful at motivating their patients todo so.form of addiction in which food intake is reinforcedby the pleasurable or positive feelingsthat follow. The action of the neurotransmitterdopamine is known to be associated with reinforcing/addictivebehaviors, and individuals witha certain variant (A1 allele) in a gene that determinesthe density of dopamine receptors are morelikely to experience the reinforcing value of food.Furthermore, obese individuals carrying that alleleare more likely than non-obese people with theallele to receive positive reinforcement from foodintake. In combination, high food reinforcementbehavior and the presence of the A1 allele result insignificantly greater food intake than either variablealone.Psychosocial Stress in an “Obesogenic”EnvironmentSeveral conceptual theories have been used toexplain the health behaviors that have led to thecurrent obesity epidemic. One often cited theoryis the social ecological model of behavior (Figure23.2), which posits that individual health behaviors(e.g., eating, exercise) occur within a multilayeredcontext encompassing interpersonal relationswithin a community governed by public policies.In the past decade, much research has focusedon the built environment (the man-made surroundingsin which human activity takes place) regardingits effects on energy intake and expenditure.In particular, the retail food environment, orthe availability and types of food in a community,has received much attention as it relates toan individual’s dietary practices and obesity risk.The main contention is that residents of communitieswith greater access to cheap calorie-dense/nutrient-poor foods (e.g., those available at conveniencestores and fast food restaurants) comparedto affordable healthy foods (e.g., fresh produceavailable in grocery stores and supermarkets)consume less healthful diets and are therefore atgreater risk of obesity and its comorbidities. Largepopulation studies have found that the presence ofsupermarkets in a community is positively associatedwith fruit and vegetable consumption, and arelatively greater number of convenience storesand fast food restaurants is associated with agreater prevalence of obesity and diabetes. Theseassociations may partly explain the racial andsocioeconomic disparities in obesity prevalence,as communities with larger minority populationsand greater poverty rates often have less access tosupermarkets and grocery stores. Paradoxically,the cost of available healthy food in low-incomecommunities is often greater than the cost of thesame food in more affluent areas, mainly due tothe lack of supermarkets, which tend to have lowerprices than smaller grocery stores.Elements of the built environment have alsobeen associated with physical activity levels.Environmental studies often categorize neighborhoodsand communities based on their “walkability,”that is, the extent to which the design of a communityallows residents to walk to conduct theirdaily activities such as shopping. Highly walkableneighborhoods are generally densely populated,

196 The Behavioral Sciences and Health CareSocietyIndividualGeneticsDietary intakePhysical activityInterpersonalBehaviors of family,friends, co-workersSocial normsCommunityGrocery storesFast foodrestaurantsPhysical activityresourcesFood pricesAgriculturalpoliciesFood systemsMedia/marketingFigure 23.2. Examples of factors related to obesity at each level of the social ecological modelhave commercial areas, and have grid-like streetpatterns. Studies have shown that residents of suchneighborhoods tend to engage in more physicalactivity compared to those living in less walkableareas. There is also some evidence that overweightand obesity are less prevalent in neighborhoods ofhigher walkability and that neighborhood “greenness”and residential density are negatively associatedwith children’s odds of becoming overweight.Although overweight and obesity are ultimatelya result of individual behaviors, other factors contributeas well. For example, technological changesin the food industry have decreased the timecost of food for consumers. Developments in areassuch as food processing, preservation, and packagingallow manufacturers to produce an increasingvariety of foods (often high fat/calorie meals andsnacks) that require minimal at-home preparation.Proponents of this “technical change theory” pointto two main facts to support it: (1) the consumptionof calories from snacks (the “meal” in whichthe most technological changes have occurred)has approximately doubled since the 1970s withno compensatory decrease in calories from regularmeals, and (2) the greatest increase in BMIand proportion of obese individuals has occurredamong married women, the group for whom thetime cost of food has decreased the most (seeWisman et al. in Recommended Readings)But it sounds healthy…Did you know…?Applebee’s Pecan Crusted Chicken Salad packs a gutwrenching1,310 calories and 81 grams of fat – that’sthe equivalent of eating more than ½ dozen KrispyKreme doughnuts!Beware!Restaurants often drown an otherwise healthy dish offresh veggies in a fat- and calorie-laden sea of dressings,cheeses, and fried meats.Try this…Ask for grilled instead of fried meats, less of the“extras,” and your dressing on the side. Many restaurantswill also let you order a ½ size salad, automaticallysaving you ½ the fat and calories (and maybe evenleave room for a sensible dessert!).

Chapter 23: Obesity 197This increase in the variety and quantity ofcheap, ready- (or nearly-ready) to-eat, unhealthyfoods has occurred in tandem with a nationwideincrease in everyday psychosocial stressors andeconomic insecurity. Studies have found severaltypes of psychosocial stress to be associated withweight gain, including job demands, difficultypaying bills, depression, generalized anxiety, andperceived constraint in life. Chronic psychosocialstress may contribute to weight gain in twoways: by increasing pleasure-seeking behaviorsthat include the consumption of highly palatablebut unhealthy foods, and by affecting the productionof hormones involved in energy metabolism,namely cortisol and other glucocorticoids. Acuteand chronic stress lead to elevated glucocorticoidlevels, which, in turn, stimulate insulin secretion,promoting both emotionally-induced food intake(“comfort feeding”) and fat deposition. Abdominaladipose depots are particularly sensitive to thecombination of these hormones.The socioeconomic gradient in obesity observed in theUS may be due in part to the chronic stress and insecurityexperienced at lower income levels. The growinggap between the richest Americans and the rest of thecountry supports the notion that social and economicpressures are contributing to the obesity epidemic.Curbing the epidemicWhat can be done to reverse the current obesityepidemic?On the individual level, preventing overweight andobesity is conceptually simple: excessive weightgain can be avoided by maintaining energy balancethrough a healthy diet and regular physicalactivity. This advice, however, can be difficult toadhere to in an obesogenic environment. Althoughhealthy eating and physical activity remain themainstays of public health messages, higher-levelinterventions are needed to promote the nationwidechange in individual behaviors that can curband reverse the obesity epidemic. Recent communityinitiatives include improving healthy foodoptions and physical activity in childcare andschool environments, passing laws to limit salesTo burn off…A McDonald’s Big Mac®You would have to…and marketing of unhealthy foods and beveragesto children, and making healthy foods more widelyavailable in corner stores of low-income communities.Taxation of sugar-sweetened beveragesand other unhealthy items has become a topic ofnational debate. Ending the country’s weight problemmust become a national priority, but it willrequire collaboration among many sectors of societyto achieve.Recommended ReadingsRun for 56 min @ 5 mph(or only 26 min @ 10 mph!)6 Oreo ® cookies Do 4,440 jumping jacksA large movie theaterpopcornA Grande CaramelFrappucino®Dance for 2 ½ hoursShovel snow for 1 hour3 Olive Garden Mow the lawn for 1 ½ hoursbreadsticks(with a push mower!)Hu F. Obesity Epidemiology. New York: OxfordUniversity Press; 2008.Sallis JF, Glanz K. Physical activity and food environments:Solutions to the obesity epidemic. MilbankQuarterly 2009; 67:123–154.White House Task Force on Childhood Obesity, Reportto the President (May 2010). Solving the Problem ofChildhood Obesity Within a Generation. Availableat http://online.wsj.com/public/resources/documents/obesityMay2010.pdfWisman JD, Capehart KW. Creative destruction,economic insecurity, stress, and epidemic obesity.American Journal of Economics and Sociology2010; 69:936–982.Yang WJ, Kelly T, He J. Genetic epidemiology of obesity.Epidemiologic Reviews 2007; 29:49–61.

198 The Behavioral Sciences and Health CareReview questions1. Children are classified as obese if they are ator above what age/gender-specific BMI percentile?A. 50thB. 66thC. 75thD. 85thE. 95thC. improving food quality in childcare environments.D. requiring all schools to allow 10 hours ofphysical education or recess per week.E. restricting the marketing and sales ofunhealthy foods and beverages to children.Key to review questions: p. 4072. Which BMI would classify an adult as overweight?A. 23.0B. 24.9C. 27.5D. 30.1E. 35.53. Which of the following has been identifiedas a contributing factor in the development ofoverweight and obesity?A. EnvironmentB. GenesC. HormonesD. StressE. All of the above4. Which of the following is true about the retailfood environment?A. Access to convenience stores and fast foodrestaurants is associated with lower risk ofdiabetes.B. Fresh produce and other healthy foods aregenerally more affordable than unhealthyfoods.C. Low-income communities often havegreater access to cheap unhealthy foodsthan to nutritious foods.D. Supermarket availability is associated withgreater obesity risk.E. Technological advances have made healthyfoods more affordable and easier to prepare.5. All of these public health interventions havebeen proposed to address the obesity epidemicEXCEPTA. imposing taxes on unhealthy foods.B. improving access to and affordability ofhealthy foods in corner stores.

A clearly structured, compact text on thebehavioral sciences for medical and otherhealth professions students, includin including practi practical features such as chapter review questionsand an annotated practice exam.The brand new edition of this easy-to-usetext presents succinct information aboutthe wide variety of social and psychological sciencesthat interact with the biological sciencesin contributing to health and illness.Based on but expanding on the Integrated SciencesModel, and focusing on the Institute ofMedicine’s key themes for medical training,the new edition is organized in sections covering:Brain Systems; Homeostatic Systems andDisorders, Individual-Environment Interaction;Development Through the Life Cycle; Social andCultural Issues; Societal and Behavioral HealthChallenges; The Health Care System, Policy,and Economics; The Clinical Relationship; andPsychopathology.New chapters deal with Physician Health,Impairment, and Misconduct; Principles of Psychotherapy;Nutrition, Metabolism, and FeedingDisorders; Somatization and SomatoformDisorders; Adjustment Disorders, Bereavement,and Demoralization; and a new look at the U.S.Health Care System. Clear appendices reviewprinciples of epidemiology and biostatistics.Each chapter begins with guidance questionsand ends with current recommended readingsand review questions. A complete 350+ questionand-answermultiple choice-type review sectionnot only allows readers to assess how wellthey have learned the material, but also highlightsimportant points and adds additionalspecific information to supplement the text.The authors of this text are experienced teachersand researchers drawn from the membershipof the Association for the BehavioralSciences and Medical Education (ABSAME) aswell as other health care educators who arenational and international experts in the behavioralsciences.“This text should be required reading for all healthsciences students and their faculties, as we move towarda system of truly collaborative, interprofessional healthcare delivery.”DeWitt C. Baldwin, Jr., MD, Professor emeritus ofPsychiatry and Behavioral Sciences, University of NevadaSchool of Medicine, Reno, NV“The person, the patient, must be the focus of health care,not the system or the profession. This outstanding book byO.J. Sahler, MD, and Jack Carr, PhD, and its integrated sciencesmodel go a long way towards making this a reality.”Albert H. Eaton, PhD, MDiv, President of the Association forthe Behavioral Sciences and Medical Education (ABSAME)“An outstanding integration of the most up-to-date scientificknowledge gathered across disciplines. A wonderfultextbook and reference for primary care providers.”Pat DeLeon, PhD, MPH, JD, former President of theAmerican Psychological Association“This volume has no peer in educating aspiring physiciansin how a biopsychosocial understanding of medicine’schallenges is the only approach a thoroughly preparedmedical practitioner can take.”Edward P. Sheridan, PhD, LHD, ABPP, former Chief ofPsychiatry Outpatient Services and Professor andChairman of the Division of Psychology at NorthwesternUniversity Medical School, Chicago, IL; currently,University Professor, Senior Vice President, and Provostemeritus at the University of Houston, TX“This is a wonderful volume incorporating informationnormally found in separate textbooks for psychiatryresidents, graduate students in clinical psychology, healthpsychology, social work, and public health.”Barry A. Hong, PhD, ABPP, Professor of Psychiatry andMedicine at Washington University, St. Louis, MO“A valuable resource for any clinician working in a medicalsetting. I plan to use it with all interns as part of theirorientation process for working in the medical setting.”Rosemary Oliva Obi, MS, LCAT, MT-BC, Music Therapist,University of Rochester Medical Center Golisano Children’sHospital, Rochester, NYISBN 978-0-88937-433-1