Behavioral Science

DEJA REVIEW TM 

Behavioral Science

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DEJA REVIEW TM 

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 

xi 

xiii 

SECTION I HUMAN DEVELOPMENT AND PSYCHOLOGY 1 

Chapter 1 EARLY STAGES OF LIFE: INFANCY TO CHILDHOOD 3 

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 

Chapter 2 MIDDLE STAGES OF LIFE: ADOLESCENCE TO ADULTHOOD 15 

Early Adulthood / 15 

Middle Adulthood / 17 


Chapter 3 LATE STAGES OF LIFE: AGING, DEATH, AND BEREAVEMENT 19 

Aging / 19 

Dying, Death, and Bereavement / 21 


Chapter 4 PSYCHOANALYTIC THEORY 25 


Chapter 5 LEARNING THEORY 35 

Associative Learning vs Nonassociative Learning / 35 


Chapter 6 SLEEP SCIENCE AND DISORDERS 43 

Normal Sleep / 43 

Abnormal Sleep / 45 

Other Sleep Changes / 47 

Clinical Vignettes / 48

viii 

Contents 

Chapter 7 SEXUALITY 49 

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 


Chapter 8 ABUSE AND AGGRESSION 57 

Children and Elder Abuse and Neglect / 57 

Domestic Partner Abuse / 60 

Sexual Violence / 61 

Aggression / 62 


Chapter 9 SUICIDE 65 

Suicide / 65 


Chapter 10 GENETIC BASIS OF BEHAVIOR 69 

Genetic Studies / 69 

Psychiatric Disorders Genetics / 69 

Neuropsychiatric Disorder Genetics / 71 

Alcoholism Genetics / 72 


Chapter 11 NEUROCHEMISTRY IN BEHAVIORAL SCIENCES 75 

Neuroanatomy / 75 

Brain Lesions / 76 

Neurotransmitters / 77 

Amines / 78 

Neuropeptides / 81 


SECTION II PSYCHIATRIC DISORDERS AND TREATMENT 83 

Chapter 12 PSYCHOTIC DISORDERS 85 

Introduction / 85 

Disorders / 85 


Contents 

ix 

Chapter 13 MOOD DISORDERS 93 


Chapter 14 ANXIETY DISORDERS 103 

Panic Disorder / 104 

Obsessive-Compulsive Disorder / 105 

Social Phobia / 106 

Posttraumatic Stress Disorder / 107 

Specific Phobia / 108 

Adjustment Disorder with Anxiety / 109 


Chapter 15 COGNITIVE DISORDERS 111 

Delirium / 111 

Dementia / 112 

Amnestic Syndromes / 115 


Chapter 16 SOMATOFORM DISORDERS 117 

Somatization Disorder / 118 

Conversion Disorder / 119 

Hypochondriasis / 120 

Body Dysmorphic Disorder / 121 

Factitious Disorder / 122 

Malingering / 123 


Chapter 17 PERSONALITY DISORDERS 125 

Cluster A: The Mad / 126 

Cluster B: The Bad / 127 

Cluster C: The Sad / 130 


Chapter 18 DISSOCIATIVE DISORDERS 135 


Chapter 19 SUBSTANCE ABUSE DISORDERS 139 


Chapter 20 EATING DISORDERS 153 


x 

Contents 

Chapter 21 CHILD PSYCHIATRY 159 

Pervasive Development Disorders / 159 

Disruptive Behavior Disorders / 161 

Attention-Deficit Hyperactivity Disorder / 162 

Other Neuropsychiatric Disorders of Childhood / 162 


Chapter 22 PSYCHOPHARMACOLOGY 165 


SECTION III 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 191 

Health-Care Insurance / 191 

Health-Care Costs / 193 

Health-Care Delivery Systems / 194 

Health Status and Determinants / 195 


Chapter 26 EPIDEMIOLOGY AND RESEARCH DESIGN 199 

Epidemiology / 199 

Research Study Designs / 201 

Testing / 203 

Measures of Association / 205 


Chapter 27 BIOSTATISTICS 209 

Statistical Distribution / 209 

Statistical Hypothesis and Error Types / 212 

Statistical Tests / 214 


Index 217

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 

Mayo Medical School 

MD/MPH Candidate 

Class of 2010 

Daniel Marcovici 

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. 

Describe Sigmund Freud’s theories of 

development. 

Describe Jean Piaget’s theories of 

development. 

Critical periods at which achievement 

of social goals need to be achieved, 

otherwise they won’t be achieved. 

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. 

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? 


characterized by a child learning 

physical skills such as walking and 

learning to use the bathroom? 


characterized by a child becoming 

assertive in their learning? 

Trust vs Mistrust: birth to 18 months 

Autonomy vs Shame and Doubt: 

age 18 months to 3 years 

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? 


characterized by a teen who achieves a 

sense of identity in politics, sex roles, 

or occupation? 


characterized by an adult determining 

whether or not they want to establish 

an intimate relationship with another 

individual? 


characterized by an adult finding ways 

to support and encourage the next 

generation? 


characterized by an adult reflecting 

on their experiences to derive 

meaning from their life? 

Industry vs Inferiority: age 6 to 12 years 

Identity vs Role Confusion: age 12 to 

18 years 

Intimacy vs Isolation: age 19 to 40 years 

Generativity vs Stagnation: age 40 to 

65 years 

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? 


characterized by focus on receiving 

pleasure through potty training? 


characterized by focus on identifying 

with adult role models and the oedipal 

complex? 


characterized by focus on expanding 

social interactions? 


characterized by focus on establishing 

a family? 

Oral phase present from birth to 

age 1 year 

Anal phase present from age 1 to 

3 years 

Phallic phase present from age 3 to 

6 years 

Latency phase present from age 6 to 

12 years 

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? 


characterized by children being more 

logical, flexible, and organized than in 

early childhood? 


characterized by being able to think 

logically, theoretically, and abstractly? 

Preoperational thought present from 

age 2 to 7 years 

Concrete operational present from 


Formal operational from age 12 to 

adulthood 

INFANT MORBIDITY AND MORTALITY 

Define premature birth. 

What are the potential outcomes of 

being a premature infant? 

In the United States, what percentage 

of births is premature? 

What are the common risk factors 

associated with premature births? 

Less than 34 weeks gestation or birth 

weight less than 2500 g 

Increased infant mortality 

Delayed physical and social development 

Emotional and behavioral problems 

Dyslexia 

Child abuse 

6% for white women and 13% for 

African American women (an average 

of 7.2 per 1000 live births) 

Low socioeconomic status 

Teenage pregnancy 

Poor maternal nutrition 

NEONATAL REFLEXES 

What are the six important neonatal 

reflexes? 

Which neonatal reflexes are present 

at birth? 

1. Moro 

2. Palmar grasp 

3. Rooting 

4. Stepping 

5. Asymmetric tonic neck 

6. Parachute 

Moro 

Palmar grasp 

Rooting 

Stepping


What is the Moro/”startle” reflex? 

What is the palmar grasp? 

What is the rooting reflex? 

What is the stepping reflex? 

At what age do the Moro, 

palmar, rooting, and stepping 

reflexes disappear? 

What is the asymmetric tonic neck? 

At what age does asymmetric tonic 

neck appear and then disappear? 

What is the parachute reflex? 

Head extension causes extremity 

extension followed by flexion. 

If a finger is placed in an infant’s palm, 

it is grasped. 

If an object is placed around an infant’s 

mouth, the infant will pursue it. 

When held upright and leaning 

forward, an infant will make walking 

motions with their legs. 

4 to 6 months 

While supine, turning of the head 

causes ipsilateral extremity extension 

and contralateral flexion. 

Present at 2 weeks and disappears 

by 6 months 

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? 

What are the developmental milestones 

at 1 month of age? 


at 2 to 3 months of age? 

Gross motor 

Fine/visual motor 

Language 

Social 

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 

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? 


at 6 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 

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 

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 

Gross motor: walks alone 

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 

Gross motor: walks backward; creeps 

upstairs 

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









at 3 years of age? 





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 

Fine/visual: removes clothes; copies 

lines 

Language: appropriate pronoun use 

Social: knows first and last names 

Gross motor: pedals tricycle; goes 

up and down stairs with alternating 

feet 

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 

Gross motor: hops and skips 

Fine/visual: catches ball; dresses alone; 

copies a cross 

Language: knows colors; counts to 10 

Social: imaginative play 

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 

1 month old 

Gross Fine/Visual 

Motor Motor Language Social 

When With eyes Startles to Fixes on face 

prone lifts tracks sound 

head 

objects to 

slightly midline; 

tight grasp 

2 to 3 months old 

Steadily holds Hands open Smiles Recognizes 

head up; at rest responsively; parents; 

when prone coos reaches for 

lifts chest 

up 

familiar 

objects or 

people 

4 to 5 months old 

Rolls front to Grasps Orients to Laughs; 

back and with both voice enjoys 

back to front; hands observing 

sits well 

environment 

supported 

6 months old 

9 months old 

Sits well Transfers Babbles Recognizes 

unsupported; hand to strangers 

sits upright hand; and has 

reaches with 

stranger 

either hand 

anxiety 

Crawls, Uses pincer Says Waves 

pulls to grasp; “dada/mama”; bye-bye; 

stand finger understands plays 

feeds “no” pat-a-cake 

12 months old 

Walks alone Throws, One to eight Imitates 

releases words other actions; 

objects than “dada/ comes when 

mama”; called; 

one-step 

commands 

cooperates 

with 

dressing 

(Continued)


Table 1.1 Developmental Milestones (Continued ) 



15 months old 

Walks Builds two- Uses four to Throws 

backward; block eight words temper 

creeps towers; tantrums 

upstairs scribbles; 

uses a cup 

18 months old 

Runs; kicks a Feeds self Points to body Plays around 

ball with parts when but not with 

utensils asked; names other 

common 

objects 

children; 

start of 

toilet 

training 

21 months old 

Squats Builds Two-word Toilet 

and five-block combinations training 

recovers towers 

24 months old 

Walks well Removes 50-word Follows twoup 

and clothing; vocabulary; step 

down stairs; copies a stranger commands; 

jumps line understands engages in 

half of speech parallel 

play 

30 months old 

Throws ball Removes Appropriate Knows first 

over hand clothes; pronoun use and last 

copies 

names 

lines 

3 years old 

Pedals Draws a Three-word Group play; 

tricycle; circle; eats sentences; shares toys 

goes up with uses plurals 

and down utensils and past 

stairs with 

tense; 

alternating 

feet 

stranger 

understands 

three-fourths 

of speech


Table 1.1 Developmental Milestones (Continued ) 



4 years old 

5 years old 

Hops and Catches Knows colors; Imaginative 

skips ball; counts to 10 play 

dresses 

alone; 

copies a 

cross 

Hops and Ties shoes Prints first Plays 

skips name cooperative 

games; 

understands 

rules and 

abides by 

them 

ATTACHMENT 

What is anaclitic depression? 

What occurs without proper 

mothering or attachment? 

What occurs during failure 

to thrive? 

Toddlers who are hospitalized 

are most likely to fear what? 

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. 

Failure to thrive 

Developmental retardation 

Poor health and growth 

High death rates, even with adequate 

physical care 

Separation from parents or care 

providers more than bodily harm or 

pain


In what age group is elective 

surgery best tolerated? 

By age 3, how does separation from 

parents or care providers affect 

children? 

How do toddlers understand death? 

At what age do children begin to 

understand the concept of death? 

In what age group do children 

begin to form relationships with 

other adults? 

At what point should adopted 

children be told that they 

are adopted? 

7 to 11 years 

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. 

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 the age of 8 years 

7 to 11 years 

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? 

How is the development through 

puberty measured? 

How many Tanner stages are there? 

What are the three categories of 

measurement? 

In girls: the onset of menstruation, 

beginning at age 11 to 12 years 

In boys: the first ejaculation, occurring at 


By the Tanner stages 

There are five Tanner stages. 

1. Male genitalia 

2. Female breasts 

3. Pubic hair


Table 1.2 Tanner Stages of Development 

Stage I 

Stage II 

Male Genitalia Female Breasts Pubic Hair 

Childhood-sized Preadolescent breasts Absent. 

penis, testes, and with elevation of the 

scrotum 

papilla only 

Enlargement of the Breast buds with Pubic hair is 

testes and scrotum elevation of breast sparse and 

and papilla 

straight with 

downy hair on 

labia/penis base. 

Stage III 

Penis enlargement Breast and areola Pubic hair is 

enlargement with curled, darker, 

ingle contour 

and coarse. 

Stage IV 

Stage V 

Scrotal skin Areola and papilla Pubic hair is 

darkening and projection with adult- type hair 

rugations are separate contour limited to the 

present. (secondary mound). genital area. 

Adult-sized and Mature breasts Pubic hair is 

-shaped penis, 

adult-quantity 

testes, and scrotum 

and -pattern and 

spreads to the 

thighs. 

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 2-3- 

month-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? 

What are the primary characteristics 

of this stage of life? 

Which Erikson stage is prevalent 

during early adulthood? 

Which life events often occur during 

this stage? 

20 to 40 years 

Role in society is defined. 

Physical development peaks. 

Sense of independence. 

Intimacy vs Isolation 

Marriage 

Having children 

Occupation 

What percentage of Americans is 60% to 70% 

married by age 30? 

What are postpartum blues? 

What is the percentage of women who 

suffer from postpartum blues? 

How long do the symptoms of 

postpartum blue last? 

Mild mood swings that may switch 

quite rapidly and occur after delivery— 

usually within a few days. 

40% to 80% (very common and 

considered normal) 

They usually resolve within 2 weeks. 

15


What can a physician do to assist 

a patient with postpartum blues? 

What is the percentage of women who 

suffer from postpartum depression? 

What are the diagnostic criteria for 

postpartum major depression? 

What complications for the mother/ 

child relationship may result from 

postpartum depression? 

When do the symptoms of postpartum 

major depression occur? 

What can a physician do to assist a 

patient with postpartum major 

depression? 

Support and reassurance 

Advise to get help with child care 

Watch for development of postpartum 

depression 

5% to 25% (making it important to 

screen for!) 

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. 

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 

Within 4 weeks after delivery (DSM-IV-TR 

criteria for “postpartum onset”), though 

some say up to 12 months after 

Psychosocial therapy 

Antidepressant medication 

May require hospitalization if severe 

What percentage of women suffer from 0.1% to 0.2% 

postpartum psychosis? 

What are characteristics of postpartum 

psychosis? 

When do the symptoms of postpartum 

psychosis occur? 

What can a physician do to assist a 

patient with postpartum psychosis? 

Which postpartum emotional reaction 

is considered normal? 

Delusions 

Hallucinations 

Mother may harm infant 

2 to 3 weeks after delivery 

Antipsychotic medication 

Hospitalization 

Note: This is a psychiatric emergency! 

Postpartum blues

Middle Stages of Life: Adolescence to Adulthood 17 

MIDDLE ADULTHOOD 

What age range constitutes middle 

adulthood? 

What are the primary characteristics of 

this stage of life? 

Which Erikson stage is prevalent during 

middle adulthood? 

What term describes the decrease in 

physiologic function that occurs 

in midlife? 

What physiologic functions decrease 

in men? 

What major reproductive change occurs 

in women? 

What are the characteristics of 

menopause? 

What medical intervention has been 

used to treat acute menopausal 

symptoms? 

How long should contraceptive 

measures continue after the 

last menstrual period in 

menopause? 

40 to 65 years 

Power 

Authority 

Generativity vs Stagnation 

Climacterium 

Endurance 

Muscle strength 

Sexual performance 

Menopause 

Lack of menstrual cycles 

Hot flashes 

Sexual Dysfunction/Vaginal Dryness 

Osteoporosis (long-term) 

Short-term estrogen replacement 

therapy (long-term not recommended) 

1 year



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 15% 

will be 65 years and older by the 

year 2020? 

Which is the fastest growing age group 

in the United States today? 

What is the average life expectancy in 

the United States? 

What factors within a population can 

have an effect on differences in life 

expectancy? 

How are the life expectancies changing 

in regard to different ethnic groups? 

What physical changes are associated 

with aging? 

85 years and older 

77 years 

Gender (females tend to live longer than 

males; an average difference of 7 years) 

Race (whites tend to live longer than 

blacks) 

White female (80 years) > black female 

(74 years) = white male (74 years) > 

black male (66 years) 

Males and African Americans are living 

longer, thus the gap between them and 

the longest living (white female) is 

decreasing. 

Sensory: impaired vision and hearing 

Visceral: decreased pulmonary, renal, 

and gastrointestinal function 

Extremities: increased fat deposits, 

osteoporosis, and decreased muscle 

mass and strength 

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? 

Which Erikson stage of development 

is characteristic of the last stage of life? 

No. Slight decreases in cognitive ability 

are usually compensated for by life 

experience and wisdom—so called 

“crystallized intelligence.” 

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? 

What factors can lead to depression in 

the elderly? 

What common disease process involving 

cognitive decline may mimic depression 

in the elderly? 

What three methods can be used to 

successfully treat depression? 

What changes in sleep patterns occur 

in the elderly? 

Major depression 

Loss of spouse, friends, and/or family 

Loss of prestige and income 

Decline of health 

Retirement 

Dementia 

1. Pharmacotherapy 

2. Psychotherapy 

3. Electroconvulsive therapy (this is 

still the most effective treatment for 

depression) 

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? 

Do psychiatric drugs produce the same 

effects in the elderly as they do in 

young adults? 

Alcohol-related disorders 

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? 

At what stage would a patient refuse 

to believe he or she is dying and say, 

“You must be reading the 

wrong chart”? 

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”? 

At what stage would a patient plead 

with a higher power for forgiveness 

and healing? 

At which stage would a patient 

become tearful, withdrawn, and 

apathetic? 

At what stage would a patient gain the 

understanding that life has come to 

an end? 

Elizabeth Kubler Ross 

Denial 

Anger 

Bargaining 

Depression 

Acceptance


What is the difference between 

bereavement and major depression? 

How long does bereavement last? 

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. 

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 

Some feelings of guilt 

Illusions 

Expressions of sadness 

Minor weight loss (8 lb) 

Poor grooming 

Few attempts to return to normal 

routine 

Severe symptoms subside in 

Severe symptoms continue for 

2 months 

Moderate symptoms subside in 

Moderate symptoms subside in 

1 month 

Tx: support groups, increased 

contact with physician, counseling, 

short-acting sedatives if needed 

Abbreviation: Tx, treatment. 

Tx: may include antidepressants, 

psychotherapy, antipsychotics, 

and electroconvulsive therapy

Late Stages of Life: Aging, Death, and Bereavement 23 


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? 

Which part of Freud’s topographic mind 

contains information that one is 

unaware of, but can be accessed 

with prompting? 

Which part of the mind contains 

thoughts of which a person is aware? 

How is the expression of the id 

regulated? 

Which part of the mind helps a person 

maintain relationships? 

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 

Preconscious 

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. 

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). 

The ego 

25


Which part of the mind incorporates 

acquired moral and ethical concepts? 

How does the ego deal with conflicts 

between the id and the superego? 

What type of thinking is primary 

process? 

Which part of the mind is controlled 

by primary process thinking? 

What is psychotherapy? 

What is the purpose of psychotherapy? 

What are the differences between 

psychodynamic psychotherapy and 

psychoanalysis? 

The superego (our conscience) 

Defense mechanisms 

It is associated with pleasure and 

instincts. This process does not involve 

logic or time and may not be linear. 

The id—this is not influenced by reality 

and focuses on pleasure and instinct 

(primary processes). 

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. 

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. 

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? 

Which technique is used to describe 

the patient expressing “whatever 

comes to mind”? 

How does the unconscious mind 

manifest impulses, wishes, 

and fears? 

What is the purpose of a defense 

mechanism? 

What are the mature defense 

mechanisms? 

What are the immature defense 

mechanisms? 

Which defense mechanism causes a 

patient to take his uncomfortable 

feelings toward an unacceptable 

target and aim it at a more acceptable 

target? 

Which defense mechanism allows one 

to use a socially acceptable way to 

combat an unacceptable impulse? 

1. Free association 

2. Dream interpretations 

3. Transference interpretations 

Free association 

Through dreams, slips of the tongue, 

and forgetting significant things 

Maintaining the ego or decreasing 

anxiety and maintaining a sense 

of self 

Humor 

Altruism 

Sublimation 

Suppression 

Acting out 

Denial 

Displacement 

Dissociation 

Fixation 

Identification 

Intellectualization 

Isolation 

Projection 

Rationalization 

Reaction formation 

Regression 

Repression 

Splitting 

Displacement 

Sublimation


How does sublimation differ from 

displacement? 


to find amusement in an otherwise 

difficult situation? 

If a patient uses intellectualization 

and isolation of affect as ways to 

deal with their discomfort, what 

personality disorder might 

he have? 

What defense mechanisms are highly 

associated with OCPD? 

How does rationalization differ from 

intellectualization? 

Which immature defense is used 

extensively by patients with borderline 

personality disorder who cannot 

integrate the good and bad aspects 

of the same person? 

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). 

Humor 

Obsessive-compulsive personality 

disorder (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.) 

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. 

Splitting


Which defense mechanism leads a 

patient to deal with an uncomfortable 

situation by “placing it on the back 

burner”? 

How does repression differ from 

suppression? 

Which defense mechanism is associated 

with a person dealing with stressful 

situations in a childlike manner? 

In which personality disorder is 

repression, regression, and 

somatization used the most? 

Which defense mechanism allows us to 

place our bad feelings about ourselves 

onto others? 

How does displacement differ from 

projection? 

Which defense mechanism causes us 

to take on the positive and negative 

behaviors of others? 

Which personality disorders use 

projection and denial as their primary 

defense mechanisms? 

How does denial differ from splitting? 

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. 

Regression 

Histrionic 

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. 


Paranoid personality disorder 

Schizotypal personality disorder 

Antisocial personality disorder 

Borderline personality disorder 

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? 

Which two personality disorders 

primarily utilize avoidance? 

If a man who recently embezzled 

money donates funds to a homeless 

shelter, what defense mechanism is 

he using? 

Which defense mechanism causes an 

individual to express unacceptable 

thoughts and feelings in a socially 

inappropriate manner? 


to avoid a painful situation by acting as 

if it never happened? 

What is the emotional reaction a patient 

has toward their physician? 

What is the emotional reaction a 

physician has to a patient? 

What are the merits of recognizing 

countertransference? 

Avoidance 

Avoidant and dependent personality 

disorders 

Altruism—assisting others to avoid 

feeling bad about oneself 

Acting out 

Denial 

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. 

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). 

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.

Table 4.1 

Defense 

Mechanism 

Description 

31 

Immature Mature 

Altruism 

Humor 

Sublimation 

Suppression 

Acting Out 

Denial 

Displacement 

Dissociation 



Projection 



Regression 

Repression 

Splitting 

Guilty feelings are alleviated by kindness to others 

Recognizing the amusing nature of an anxiety-provoking or adverse situation 

Channeling unacceptable impulses into acceptable actions 

Voluntary blocking of an idea or feeling from conscious awareness 

Undesirable feelings and thoughts are expressed through actions 

Refusing to accept facts about an unpleasant reality 

Transferring feeling about one thing to something else 

Detaching from oneself; emotionally or mentally 

Modeling one’s behavior after someone more powerful 

Using facts and logic to avoid emotions 

Attributing one’s feelings to an external source 

Proclaiming logical reasons for actions actually performed for other reasons 

Process whereby a warded-off idea or feeling is replaced by an unconsciously derived 

emphasis on its opposite 

Returning to a less mature stage of development 

Involuntary blocking of an idea or feeling from conscious awareness 

Belief that people are either all good or all bad 

(Continued)

Table 4.1 (Continued ) 

Defense 

Mechanism 

Example 

32 

Immature Mature 

Altruism 

Humor 

Sublimation 

Suppression 

Acting Out 

Denial 

Displacement 

Dissociation 



Projection 



Regression 

Repression 

Splitting 

Criminal makes large donation to charity. 

Nervous surgeon jokes about an upcoming procedure. 

Aggressiveness used to succeed in business ventures. 

Choosing not to think about life stresses during work. 

A teenager punches a hole in the wall. 

An HIV-positive man adamantly states he is healthy. 

Mother yells at her child because she is angry at her husband. 

Floating above one’s body during a traumatic event. 

An abused child becomes a bully. 

A newly diagnosed cancer patient calmly describes the pathogenesis of their disease. 

A woman who fantasizes about another man thinks her husband is cheating on her. 

Saying a job was not important, after getting fired. 

A patient with sexual thoughts enters a monastery. 

An adult clutching a sentimental teddy bear. 

Traumatic childhood events remain buried in the unconscious. 

A patient says that all men are cold and insensitive but that women are warm and friendly.



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? 


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? 


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 

What is behaviorism? 

It is a learning theory based on the idea 

that behavior is a product of learning 

through association or reinforcement. 

ASSOCIATIVE LEARNING VS NONASSOCIATIVE LEARNING 

What is associative learning? 

What are associative learning processes? 

What is nonassociative learning? 

What are nonassociative learning 

processes? 

Learning that occurs when a connection 

or pairing is made between a particular 

stimulus and a particular response 

Classical conditioning 

Operant conditioning 

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). 

Observational learning 

Habituation 

Sensitization 

Associative Learning 

Imprinting 

What is 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. 

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? 

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. 

CS 

2 

US 

1 

3 

UR 

CR 

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. 

Note: UR and CR are the 

accurate terminology; the 

response itself is still the same. 

Bell 

3 

Doctor’s office 

3 

2 

Salivation 

2 

Nausea 

Food Salivation 

1 

Pavlov’s example 

Figure 5.1 

Chemotherapy Nausea 

1 

Medical example

Learning Theory 37 

What is the term describing a similar 

stimulus to the conditioned stimulus 

eliciting the same response? 

What is a medical example of classical 

conditioning? 

What is extinction? 

Is it possible for the conditioned 

response to be paired with the 

conditioned stimulus after extinction 

has taken place? 

What does learned helplessness mean? 

What mood disorder may be explained 

by the theory of learned helplessness? 

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. 

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. 

It is the disappearance of the conditioned 

response if the conditioned and 

unconditioned stimuli are no longer 

presented together. 

Yes, this is called spontaneous recovery. 

The effect of repeatedly pairing an 

adverse stimulus to the inability to 

escape, leading to thoughts that no 

efforts will be successful 

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? 

What are the different consequences 

in operant conditioning? 

It is the idea that a behavior is learned 

because of the reward or punishment 

associated with it. 

Positive reinforcement 

Negative reinforcement 

Punishment 

Extinction


What are reinforcers? 

What is positive reinforcement? 

What is negative reinforcement? 

What type of reinforcement increases 

the likelihood of a behavior occurring 

again? 

What will decrease the likelihood 

of a behavior occurring? 

What is shaping? 

When is shaping used? 

What is the definition of punishment? 

What is the definition of extinction 

in operant conditioning? 

What is an example of extinction? 

Any event or stimulus that increases the 

likelihood of the behavior occurring 

again 

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. 

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. 

Positive and negative reinforcement 

Punishment (note the contrast between 

negative reinforcement and punishment) 

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. 

It is a progressive modification of 

behavior which occurs by reinforcement 

of behavior which is close to the desired 

outcome. 

Presentation of an aversive stimulus to 

reduce the likelihood of an unwanted 

behavior occurring 

Extinction is the disappearance of a 

certain behavior when the reinforcement 

is no longer present. 

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.


What are the different schedules of 

reinforcement? 

Which reinforcement shows the fastest 

extinction when reinforcement is 

taken away? 

What is variable ratio reinforcement? 


classical and operant conditioning? 

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 

Continuous 

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 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? 

If a person observes others and then 

imitates their behavior, what is that 

behavior called? 

What four aspects are needed in order 

for a person to be able to model? 

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. 

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. 

1. Attention to the model 

2. Retention of details 

3. Motor reproduction 

4. Motivation and opportunity


Where in medicine is modeling used? 

Can modeling have a negative outcome? 

Can modeling have a positive outcome? 

What is habituation? 

What is an example of habituation? 

How is habituation used in medicine? 

How do you describe flooding? 

What is an example of flooding? 

How do you describe systematic 

desensitization? 

The common saying, “see one, do one, 

teach one,” is a description of modeling 

in learning how to do medical 

procedures. 

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. 

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). 

Habituation occurs when stimulus 

presentation results in decreased 

responsiveness. 

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. 

Habituation is used to overcome 

phobias. Some of the specific techniques 

using habituation are flooding and 

systemic desensitization. 

It is excessive presentation of the 

stimulus to achieve quick habituation 

by preventing escape and forcing 

a reduction in the associated 

behavior. 

One could force an individual with 

an obsession about germs to touch 

a toilet. 

In systematic desensitization, the 

patient is gradually exposed to 

anxiety-producing situations while 

simultaneously teaching relaxation or 

anxiety-reducing techniques.


What is sensitization? 

What is an example of sensitization? 

Sensitization occurs when stimulus 

presentation results in increased 

responsiveness and/or generalization of 

response to other stimuli. 

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? 

Which term did Binet use to describe 

the average intellectual age of people 

with a specific chronological age? 

Which scale is used to determine a 

person’s IQ? 

Intelligence 

Mental age 

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? 

If a person has an IQ



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 

What are the normal stages of sleep? 

REM (rapid eye movement) and NREM 

(nonrapid eye movement). NREM is 

divided into four stages: 1, 2, 3, and 4. 

Awake 

REM 

Sleep stage 

Stage 1 

Stage 2 

Stage 3 

Stage 4 

Time asleep 

Figure 6.1 

What is slow wave sleep? 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 

43


What waveforms are seen in 

REM sleep? 

Where else are beta waves seen? 

What waveforms are associated with 

Stages 1 and 2 of NREM? 

Beta waves. These are of highest 

frequency. 

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. 

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 REM: 25% 

normal adult spend in each stage NREM: 75% 

of sleep? 1. Stage 1: 5% 

2. Stage 2: 45% 

3. Stage 3: 25% 

4. Stage 4: 25% 

What is REM latency? 

What is the length of REM latency 

in an adult? 

Besides rapid eye movements, what 

other physiologic changes occur in 

REM sleep? 

How is this different from the 

physiologic changes in NREM sleep? 

Which neurotransmitter usually 

initiates sleep? 

REM latency is the length of time after 

falling asleep before REM sleep occurs. 

REM latency in an adult is approximately 

90 minutes. The REM sleep cycle then 

repeats itself approximately every 

90 minutes thereafter. 

Pulse, respiration, blood pressure, and 

brain oxygen use increase. There is 

penile/clitoral erection, dreaming, and 

decreased skeletal muscle tone. 

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! 

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? 

How does REM change with age? 

What effect does dopamine have on the 

sleep cycle? 

Acetylcholine (ACh) from the basal 

forebrain and norepinephrine (NE) from 

the locus ceruleus. ACh increases REM 

sleep and NE decreases it. 

Time spent in REM decreases with age. 

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? 

What is the most common type 

of sleep disorder? 

What is a primary sleep disorder? 


dyssomnias and parasomnias? 

Name the five major dyssomnias 

How long must you have problems 

with insomnia before primary 

insomnia can be diagnosed? 

About one in three 

Insomnia, which includes problems 

initiating and maintaining sleep. 

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 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. 

1. Primary insomnia 

2. Primary hypersomnia 

3. Narcolepsy 

4. Breathing-related sleep disorder 

5. Circadian rhythm sleep disorder 

At least 1 month


What interventions other than 

medications can be useful 

in insomnia? 

What is the subtype of recurrent 

primary hypersomnia associated with 

obesity, impulsivity, hyperphagia, 

hypersexuality, and disorganized 

thought called? 

Other than daytime sleepiness and 

“sleep attacks,” what symptoms are 

classically associated with narcolepsy? 

Which class of drugs is normally used 

to treat narcolepsy? 

Why are people with breathing-related 

sleeping disorder chronically sleepy 

during the day? 

What is the most common cause 

of breathing-related sleep disorder 

and how is it treated? 

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)? 

What are the complications from 

untreated OSA? 

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. 

Kleine-Levin syndrome 

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 

Stimulants, eg, Ritalin 

During the night they frequently stop 

breathing and then are awoken by 

hypoxia. These frequent arousals 

prevent the patients from getting deep, 

restful sleep. 

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.) 

Loud snoring and periods of time 

where the patient appears to stop 

breathing 

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? 

What are the three most common causes 

of a circadian rhythm sleep disorder? 

During which phase of sleep would 

you expect nightmares to occur in? 

What are the similarities between sleep 

terrors and sleepwalking? 

How could you clinically differentiate 

sleep terror from sleepwalking? 

What is the treatment of sleep terrors 

and sleepwalking? 

You risk further compromising the 

patient’s ventilation by respiratory 

depression. 

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 

REM 

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. 

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. 

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 


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? 

Gonad differentiation is dependent 

upon the presence of which 

chromosome? 

Which gene present on the 

Y chromosome influences gonad 

development? 

Which duct system present in male 

embryos helps form genitalia? 

Which duct system in female embryos 

help form female genitalia? 

Which organ secretes hormones that 

direct the differentiation of male 

internal and external genitalia? 

How does exposure to different levels 

of hormones during prenatal life 

influence humans? 

What term describe an individual’s 

sense of being male or female? 

At which age(s) does gender awareness 

become evident? 

What term describes the expression 

of gender identity in society? 

What term describes the conflict people 

experience when they feel as if they 

were born as the wrong gender? 

Female 

Y chromosome 

SRY Gene, which makes testisdetermining 

factor 

Wolffian duct system 

Mullerian duct system 

Testes 

It causes gender differences in certain 

areas of the brain. 

Gender identity 

2 or 3 years of age 

Gender role 

Gender identity disorder 

49


According to the DSM-IV-TR 

is homosexuality a dysfunction 

of sexual expression? 

What is the difference between sex 

and gender? 

What type of behavior in childhood 

may be predictive of later homosexual 

orientation? 

Which hormones have been shown 

to influence sexual orientation? 

Which evidence has been reported, 

which indicates that genetics plays 

a role in homosexuality? 

On which chromosome have genetic 

markers been found in homosexuals? 

No, it is a normal variant. 

Sex refers to the genetics of the 

individual (XX or XY), gender is 

what a person identifies as 

(male or female). 

Cross-gender behavior → stronger 

correlation in males 

Prenatal hormones → low levels of 

androgens in males and high levels of 

androgens in females 

Higher concordance rate observed in 

monozygotic twins than in dizygotic 

twins 

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? 

What is the genotype of a person with 

androgen insensitivity? 

What is the phenotype of a person with 

androgen insensitivity? 

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? 

Androgen insensitivity which is also 

called testicular feminization 

XY 

Female 

Congenital adrenal hyperplasia 

XX 

Female with genitalia that are masculine

Sexuality 51 

What is the sexual orientation of 33% 

of patients with congenital adrenal 

hyperplasia? 

Which disorder is characterized by a 

short stature, webbed neck, and 

streak ovaries? 


Turner syndrome? 


Turner syndrome? 

Homosexual 

Turner syndrome 

XO 

Female 

HORMONES AND THEIR INFLUENCE ON BEHAVIOR 

Which hormone may be decreased by 

an increase in stress? 

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? 

Which hormone is believed to play the 

most important role in sex drive in 

both genders? 

Which hormone may decrease sexual 

behavior and interest in women? 

Testosterone 

1. Androgen antagonists 

2. Estrogens 

3. Progesterone 

Testosterone 

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? 

What is the primary characteristic of 

the excitement stage in men? 

What are characteristics of the 

excitement stage in women? 

1. Excitement 

2. Plateau 

3. Orgasm 

4. Resolution 

Penile erection 

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? 

What are characteristics of the recovery 

stage in men? 

What happens to the refractory period 

of men as they age? 

What is the primary characteristic 

of the recovery stage in women? 

What are characteristics of the refractory 

period that are common to both men 

and women? 

Nipple erection 

Elevation of blood pressure, pulse, and 

respiration 

Refractory period in which stimulation 

is not possible 

Increases 

Minimal or no refractory period 

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? 


pain associated with sexual intercourse? 

Which gender is most likely to 

experience dyspareunia? 


inability to maintain vaginal lubrication 

throughout the duration of a sexual act? 


decreased interest in sexual activity? 


problems with maintaining erections? 

Which disorder is characterized by an 

inability to achieve an orgasm? 


anxiety and ejaculation before 

a man desires? 

Which stage of the sexual response 

cycle is affected by premature 

ejaculation? 

Sexual dysfunction 

Dyspareunia 

Females 

Female sexual arousal disorder → occurs 

in approximately 20% of women 

Hypoactive sexual desire 

Male erectile disorder also called 

impotence 

Orgasmic disorder → this disorder can 

be lifelong or acquired. 

Premature ejaculation 

Plateau phase → absent or reduced

Sexuality 53 


avoidance or aversion to sexual 

activity? 


painful muscular spasms in the outer 

one-third of the vagina making pelvic 

examination or sexual intercourse 

difficult? 

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? 

What is the primary goal of the squeeze 

technique? 

Which segment of the nervous system 

is used to initiate an erection? 

Which segment of the nervous system 

is used to initiate an ejaculation? 

What is a mnemonic to remember this? 

Which behavioral technique(s) are used 

to reduce anxiety associated with 

sexual performance? 

Which drug is used to treat erectile 

dysfunction by blocking the 

phosphodiester-5 (PDE-5) enzyme 

thereby inhibiting cyclic guanosine 

monophosphate (cGMP)? 

What is the role of cGMP in sexual 

stimulation of the penis? 

Which drug is used to increase the 

availability of dopamine in the brain 

in patients with erectile disorder 

and female arousal disorder? 

What injection method is used to treat 

erectile dysfunction? 

Which vasodilators are commonly 

injected in intracorporeal injection? 

Sexual aversion disorder 

Vaginismus 

Sensate-focus exercise 

To treat premature ejaculation 

Parasympathetic 

Sympathetic 

Point and Shoot 

Hypnosis 

Relaxation techniques 

Systematic desensitization 

Sildenafil citrate (Viagra) 

It is a vasodilator which allows an 

erection to persist. 

Apomorphine (Uprima) 

Intracorporeal injection of vasodilators 

Papaverine 

Phentolamine


PARAPHILIAS 

What term describes the use of 

unusual objects of sexual desire or 

unusual sexual activities? 

Which paraphilia is most common and 

is characterized by a person who 

achieves sexual gratification from 

children

Sexuality 55 

Which postmyocardial infarction 

patients can resume sexual activity? 

Which problem is common in 

diabetic men? 

What are the two main causes of 

erectile dysfunction in diabetics? 

What is the primary treatment for 

erectile dysfunction in diabetics? 

What effect does spinal cord 

dysfunction have on sexual 

functioning in men? 

What effect does pregnancy have on 

sexual functioning? 

During what time period prior to 

pregnancy should a woman 

cease sexual activity? 

Patients who can tolerate increases in 

heart rate from 110 to 130 bpm 

Erectile dysfunction 

1. Diabetic neuropathy 

2. Vascular changes 

Metabolic control monitored by 

hemoglobin A 1c level 

Decreased fertility 

Erectile dysfunction 

Orgasmic dysfunction 

Reduced testosterone levels 

Retrograde ejaculation into the bladder 

Decreased sex drive → most common. 

Increased sex drive and pelvic 

vasocongestion may occur. 

4 weeks before expected delivery 

EFFECTS OF DRUGS AND NEUROTRANSMITTERS ON SEXUALITY 

Decreased availability of which 

neurotransmitter(s) causes a decrease 

in erection? 

Increased availability of which 

neurotransmitter(s) causes a 

decrease in ejaculation and orgasm? 

Increased availability of which 

neurotransmitter(s) causes an increase 

in erection? 

Which drug(s) of abuse causes 

increased libido with acute use? 

Which drug(s) of abuse causes 

increased libido? 

Dopamine (eg, chlorpromazine, 

haloperidol) 

Norepinephrine β (eg, propranolol, 

metoprolol) 

Serotonin (eg, fluoxetine, sertraline, 

trazodone) 

Dopamine (eg, levodopa) 

Norepinephrine in α 2 in the periphery 

(eg, yohimbine) 

Alcohol 

Marijuana 

Amphetamines 

Cocaine


Which drug(s) of abuse causes erectile 

dysfunction due to increased estrogen 

availability as a result of liver damage? 

Which drugs(s) of abuse causes reduced 

testosterone levels in men and lowered 

pituitary gonadotropin levels in women? 

Which drug(s) of abuse causes reduced 

libido and inhibited ejaculation? 

Alcohol → with chronic use 

Marijuana → with chronic use 

Heroin 

Methadone 


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

CHAPTER 8 

Abuse and Aggression 

CHILD AND ELDER ABUSE AND NEGLECT 

What are the primary types of child 

and elder abuse? 

What are the primary traits of a 

child abuser? 

What traits in a child make them more 

likely to be abused? 

What is the most common age range 

of children that are abused? 

What are key signs of child neglect? 

What are common sites of bruises on 

a victim of child abuse? 

What type of marks might one see on a 

victim of child abuse? 

What are characteristics of the fractures 

on a victim of child abuse? 

Physical 

Sexual 

Emotional 


Young parents 

Substance abuse 

Social isolation 

Stress in the household 

History of victimization by spouse or 

caretaker 

Child that has already been abused 

Low birth weight, premature infant 

Learning disability or language disorder 

Adopted child or stepchildren 

Hyperactive 


What are the two primary burn types 

on victims of child abuse? 

What are other warning signs for child 

abuse/non-accidental trauma? 

What is the classic physical finding 

of shaken baby syndrome? 

What type of cultural healing practices 

may leave markings that are important 

to distinguish from child abuse? 

What are the primary traits of an 

elder abuser? 

What are the primary traits of an elder 

who experiences elder abuse? 

What are key signs of elder neglect? 

What are characteristics of the bruises 

seen on a victim of elder abuse? 

What is the annual incidence of 

child sexual abuse cases in the 

United States? 

Has the likelihood of reporting child 

sexual abuse increased or decreased 

when compared with the past? 

1. Cigarette burns 

2. Immersion burns on legs, feet, or 

buttocks → child is immersed in 

scalding water 

History inconsistent with level of child’s 

motor development, bite marks, 

and any facial trauma or bruising 

Retinal hemorrhage 

Cupping (use of heated cups to suction 

out illness) 

Coining or Spooning (rubbed on body 

leaving linear marks) 


Social isolation 


Close relationship to the abused (eg, 

spouse, offspring) → person with whom 

the elder lives and receives financial 

support from 

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 

Lack of proper nutrition 

Poor personal hygiene 

Lack of proper medication or health 

aids (eg, prescription drugs, dentures, 

cane) 

Bilateral arm bruises from being 

grabbed 

More than 250,000 cases 

Increased

Abuse and Aggression 59 

Which gender is more likely to report 

sexual abuse during their lifetime? 

Which gender is most likely to 

be the perpetrator of child 

sexual abuse? 

Will the perpetrator of a child sexual 

abuse more likely be a stranger or 

someone the child knows? 

What are some traits of child sexual 

abusers? 

What is the primary age range of 

children who are victims of 

sexual abuse? 

What emotions is the victim of a child 

sexual abuse likely to experience? 

What are the common physical signs 

of child sexual abuse? 

What are common psychological signs 

of child sexual abuse? 

What are common physical signs of 

elder sexual abuse? 

What types of emotional abuse do 

children experience? 

Girls → 25% will report vs 12% boys 

Males 

Relative or acquaintance (eg, father, 

uncle, friend of the family, etc) 

Interpersonal relationship problems 

(eg, marriage problems) 

History of substance abuse 

May have a history of pedophilia 

9 to 12 years of age 

Guilt 

Shame 

Fear of abuser’s response if he or she 

notified someone else of his or her 

experience 

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. 

Inappropriate knowledge about sexual 

events out of proportion for a given age 

range 

Excessive initiation of sexual activity 

with peers 

Genital bruising 

Vaginal bleeding in women 

Lack of caregiver attention and love 

Physical neglect 

Caregiver rejection


What types of emotional abuse do 

elders experience? 

How many cases of child and elder 

abuse are reported annually? 

What is the physician’s responsibility 

if they suspects child or elder abuse? 

Neglect of needed care (eg, medical, 

hygiene, etc) 

Economic exploitation 

1,000,000 cases each 

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? 

What factor can greatly increase the 

likelihood of an abused person being 

killed by their abuser? 

What is the primary gender of the 

perpetrator of domestic violence? 

What are the characteristics of the 

abuser in a domestic violence situation? 

What are the characteristics of the 

abused in a domestic violence situation? 

What characteristic is common to both 

the abused and the abuser in a 

domestic violence situation? 

What is the role of the physician, in 

terms of reporting, if notified of 

domestic violence abuse? 

Broken bones 

Bruises 

Blackened eyes 

If the abused person leaves the abuser. 

Male 


Angry 

Threatens to kill the abused 

Apologetic after abuse has occurred 

May be pregnant 

May not report abuse to police 

May not leave the abuser 

Blame themselves for the abuse 

Emotional and financial dependence on 

the abuser 

Low self-esteem 

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.


SEXUAL VIOLENCE 

What is the definition of sexual assault? 

What are examples of force that can be 

used to commit a sexual assault? 

What is the definition of consent? 

What term describes oral and anal 

penetration? 

What is the primary age group 

of a rapist? 

What is the racial background of a 

perpetrator of sexual assault? 

Which substance is most frequently 

used in cases of sexual assault? 

What percentage of rapes are 

acquaintance rapes (ie, the victim 

knows the perpetrator)? 

What percentage of rapes are reported 

to the police? 

What is the age group most likely to 

experience a sexual assault? 

What is the most common place 

for a sexual assault to occur? 

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. 

Manipulation 

Coercion 

Physical force 

Use of weapons 

Use of isolation 

Use of substances—alcohol and other 

drugs 

Giving permission by giving a “yes” 

response 

Sodomy 


Which disorder do/may sexual assault 

survivors experience? 

Which type of treatment is the best 

option for survivors of sexual assault? 

Is it possible for spouses to be 

convicted of committing a sexual 

assault against each other? 

What terms describes consensual sex 

that is considered rape? 

With which group(s) of people would 

consensual sex be considered 

statutory rape? 

What is the role of the physician 

if they suspect a sexual assault? 

Posttraumatic stress disorder 

Group therapy 

Yes 

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 

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? 

Which weapon is most commonly used 

in a homicide? 

What are risk factors for being victims 

of homicide? 

Which racial group is most likely to be 

affected by a homicide? 

How does violence on television or 

video games influence aggression 

in children? 

Which gender is most likely to be most 

aggressive? 

Decreased 

Guns 

Male sex 


Alcohol and drug users 


Why are many body builders and some 

professional athletes likely to show 

increased aggression? 

Use of which drugs is associated with 

increased aggression? 

Which neurotransmitter(s) is associated 

with increased aggression? 

Which neurotransmitter(s) is associated 

with decreased aggression? 

What type of injury is most likely to be 

associated with violence? 

Use of androgenic or anabolic steroids 

increases aggression. 

Alcohol 

Amphetamines 

Cocaine 

Phencyclidine 

Marijuana (high doses) 

Dopamine 

Norepinephrine 

Serotonin 

γ-Aminobutyric acid (GABA) 

Head injury 


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? 

Where does suicide rank as a cause of 

death in the United States? 

What are risk factors for committing 

suicide? 

Who commits suicide more frequently, 

men or women? 

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. 

As of 2002, suicide ranks 10th as the 

leading cause of death. 

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. 

65


What accounts for this difference? 

What age group has the highest 

suicide rate? 

Men tend to use more lethal means 

(firearms, hanging) and women less 

lethal (pill overdose). 

• The elderly (65 and older). Despite 

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. 

What has happened to the suicide rate It has risen significantly over the last 

in child and adolescent groups over 40 years with a mortality rate of 12%, 

the last 40 years? though declined since 1990. 

What is the most significant risk factor 

of suicide? 

What are other risk factors for suicide 

(in decreasing order)? 

How is suicide most commonly 

committed or attempted? 

Is there racial disparity among those 

who commit suicide? 

What are the most common comorbid 

medical disorders associated 

with 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. 

1. Persons >45 years 

2. Alcohol dependence 

3. History of violence or aggression 

4. Male gender 

Firearms are the number one method 

for completed suicide, regardless of 

gender. 

Other common methods include 

jumping, hanging, overdose, 

and drowning. 

Yes, whites commit suicide more than 

any other group. However, the suicide 

rate among young black males is slowly 

increasing. 

Major Depressive Disorder 

Anxiety Disorders 

Posttraumatic Stress Disorder (PTSD) 

Schizophrenia 

Bipolar Disorder 

Personality Disorders 

Substance Abuse

Suicide 67 

At what stage, in treated major 

depression, is suicide attempted? 

Are there special concerns about 

children and adolescents treated 

for depression? 

When do you assess for suicidality? 

What is the difference between active 

and passive suicidal ideation? 

Can suicide attempts be predicted? 

How can suicidal ideation be managed? 

What antidepressant would be the first 

choice in a suicidal patient? 

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. 

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. 

At every follow-up assess for: 

• Ideation 

• Plan (possibility and practicality) 

• Intent to carry out the plan 

• Access to firearms 

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.”) 

There is no reliable means to predict 

suicide attempts with a reasonable 

degree of specificity and sensitivity. 

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. 

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. 


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? 

What type of study compares the 

frequency of disease in a proband 

(affected individual) with its frequency 

in the general population? 

What type of study compares 

monozygotic and dizygotic twins 

to determine the effects of genetic 

factors from environmental factors 

of disease? 

This term describes if both twins have 

a given trait. 

What type of twins is more likely 

to have a higher likelihood of having 

a disease that is genetic in origin? 

Pedigree study 

Family risk study 

Adoption study 

Concordance 

Monozygotic twins 

PSYCHIATRIC DISORDERS GENETICS 

What is the prevalence of schizophrenia 1% 

in the general population? 

In which gender is schizophrenia more 

likely? 

Which persons have a higher likelihood 

of developing schizophrenia? 

Equal in males and females 

Persons with a close genetic relationship 

69


Genetic markers on which 1, 6, 8, and 13 

chromosome(s) are associated with 

schizophrenia? 

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 10% 

schizophrenia if you are a first-degree 

relative of an affected individual? 

What is the likelihood that a child 40% 

will develop schizophrenia if both 

parents have the disorder? 

What is the likelihood that the 50% 

monozygotic twin of a patient with 

schizophrenia will develop the 

disorder? 


any mood disorder if you are a firstdegree 

relative of a person with bipolar 

disorder? 


any mood disorder if someone is a child 

with both parents who have bipolar 

disorder? 

What is the likelihood of developing 80% to 90% 

bipolar disorder if you are the 

monozygotic twin of a person with 

the disorder? 

Is the genetic component stronger for 

schizophrenia or bipolar disorder? 

In which gender is the lifetime 

prevalence of a major depressive 

disorder higher? 

Bipolar disorder 

Females 

What is the percentage of males who 10% 

will develop a major depressive 

disorder in their lifetime? 

What is the percentage of females 15% to 20% 

who will develop a major depressive 

disorder in their lifetime?

Genetic Basis of Behavior 71 

Do personality disorders have a higher 

concordance in monozygotic twins 

demonstrating that they have a genetic 

component? 

If a person has antisocial personality 

disorder, what psychiatric condition(s) 

will be prevalent in relatives? 

If a person has avoidant personality 



If a person has borderline personality 



If a person has histrionic personality 



If a person has schizotypal personality 



Yes 

Alcoholism 

Attention-deficit hyperactivity disorder 

(ADHD) 

Anxiety disorder 

Major depressive disorder 


Somatization disorder 

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 Chromosome 21 

Down syndrome, and is also implicated Note: Down syndrome patients often 

in some cases of Alzheimer disease? develop early-onset Alzheimer. 

What other chromosome(s) have been Chromosomes 1 and 14 

identified to be associated with 

Alzheimer disease? 

Which gene has been implicated in The gene encoding Apolipoprotein 

many cases of Alzheimer disease? E4 (Apo E4) 

In which chromosome is the Apo E4 Chromosome 19 

gene located? 

What disease has an abnormal gene 

on the short end of chromosome 4? 

What is the most common genetic cause 

of mental retardation? 

Huntington disease 

Down syndrome


What is the second most common 

genetic cause of mental retardation? 

What disorder, characterized by verbal 

and motor tics, has a genetic 

component? 

Fragile X syndrome 

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 60% 

alcoholism in monozygotic twins? 

What is the concordance rate of 30% 

alcoholism in dizygotic twins? 

Which gender offspring of alcoholics 

is more likely to become alcoholics 

themselves? 

In which age group is the genetic 

influence of alcoholism strongest 

in males? 

Male offspring 

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 


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? 

What are the two main components 

of the CNS? 

Which brain structures connect 

the cerebral hemispheres? 

Which hemisphere is usually the 

dominant hemisphere? 

What is the primary role of the left 

hemisphere? 

Which hemisphere is usually the 

nondominant hemisphere? 

What is the primary role of the right 

hemisphere? 

What are the components of the 

peripheral nervous system? 

How many cranial nerves are there? 

How many spinal nerves are there? 

1. Central nervous system (CNS) 

2. Peripheral nervous system (PNS) 

1. Brain 

2. Spinal cord 

Corpus callosum 

Commissures: anterior, posterior, 

hippocampal, and habenular 

Left hemisphere 

It governs our ability to express 

ourselves in language. 

Right hemisphere 

It governs perceptual functions and the 

analysis of space, geometrical shapes, 

and forms. 

Nerve fibers outside the CNS including 

cranial nerves, spinal nerves, and 

peripheral ganglia 

12 cranial nerves 

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? 

What are the components of the 

autonomic nervous system? 

Motor information: away from the CNS 

Sensory information: to the CNS 

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? 


consequences of a parietal lobe lesion? 


consequences of a temporal lobe lesion? 


consequences of a hippocampus lesion? 


consequences of an amygdala lesion? 


consequences of a reticular system 

lesion? 


consequences of a basal ganglia lesion? 


consequences of a hypothalamus 

lesion of the ventromedial nucleus? 

Deficits in concentration, judgment, 

motivation, and orientation 

Disinhibition 

Personality and emotional changes 

Right parietal lobe → (contralateral 

neglect) result in neglecting part of the 

body or space 

Left parietal lobe → verbal deficits 

Hallucinations 

Memory deficits 

Personality changes 

Bilateral damage to hippocampus leads 

to massive anterograde and some 

retrograde amnesia. 

Unilateral damage of hippocampus 

leads to memory storage and retrieval 

problems. 

Kluver-Bucy syndrome → uninhibited 

behavior, hyperorality, hypersexuality 

Sleep-wake cycle changes 

Tremor or other involuntary movements 

as seen in Parkinson or Huntington 

diseases 

Decreased satiety → leads to obesity

Neurochemistry in Behavioral Sciences 77 


consequences of a hypothalamus lesion 

of the lateral nucleus? 



of the anterior hypothalamus? 



of the posterior hypothalamus? 



of the septate nucleus? 



of the suprachiasmatic lesion? 

Decreased hunger → leads to weight loss 

Disturbances of parasympathetic 

activity 

Disturbances of body cooling 

Disturbances of heat conservation 

Change in sexual urges and emotions 

Disturbances of circadian rhythm 

NEUROTRANSMITTERS 

What are the four main steps involved 

in neurotransmitter release? 

What are the two different types of 

neurotransmitters? 

What are the two main excitatory and 

inhibitory neurotransmitters 

in the CNS? 

Which factors contribute to the 

magnitude of reaction 

neurotransmitters 

have on neurons? 

What are the three major classes of 


How are neurotransmitters removed 

from the synaptic cleft? 

1. Presynaptic neuron stimulation. 

2. Neurotransmitter release. 

3. Neurotransmitter moves across 

synaptic cleft. 

4. Neurotransmitter acts on 

postsynaptic neuron receptors. 

1. Excitatory: increase neuron firing 

2. Inhibitory: decrease neuron firing 

1. Excitatory: glutamate 

2. Inhibitory: γ-aminobutyric acid 

(GABA) 

1. Affinity of receptors 

2. Number of receptors 

1. Amino acids 

2. Biogenic amines 

3. Peptides 

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 

Acetylcholine 

Alzheimer 

Disease Anxiety Depression Mania Schizophrenia 

↓ 

Dopamine ↓ ↑ ↑ 

GABA 

Norepinephrine ↑ ↓ 

↓ 

Serotonin ↓ ↓ ↑ 

AMINES 

Which amines are included in the 

biogenic amines, which are also called 

the monoamines? 

What is the monoamine theory 

of depression? 

Why are metabolites of monoamines 

measured in psychiatric studies? 

What type of biogenic amine 

is dopamine? 

In which psychiatric condition(s) is an 

altered level of dopamine evident? 

How is dopamine synthesized? 

Catecholamines 

Ethylamines 

Indolamines 

Quaternary amines 

It proposes that there is an underlying 

neuroanatomical basis for depression 

due to deficiencies of central 

noradrenergic and/or serotonergic 

systems. 

They may be present in higher levels 

than the primary monoamines. 

Catecholamine 

Mood disorders 

Parkinson disease 

Schizophrenia 

By the conversion of tyrosine to 

dopamine by tyrosine hydroxylase 

tyrosine hydroxylase 

tyrosine ⎯⎯⎯⎯⎯⎯⎯⎯⎯→ dopamine


What is the main metabolite 

of dopamine? 

In which psychiatric condition(s) can 

there be an increased concentration 

of HVA? 


there be a decreased concentration 

of HVA? 

What type of biogenic amine is 

norepinephrine? 

What behavioral factors does 

norepinephrine alter? 

How is norepinephrine synthesized? 

Homovanillic acid (HVA) 

Psychotic disorders 

Schizophrenia 

Alcoholism 

Depression 


Catecholamine 

Anxiety 

Arousal 

Learning 

Memory 

Mood 

Dopamine is converted to 

norepinephrine by β-hydroxylase. 

β-hydroxylase 

dopamine ⎯⎯⎯⎯⎯⎯→ norepinephrine 

Where are most noradrenergic neurons 

located in the brain? 

What are the metabolites of 

norepinephrine? 


there be a decreased concentration 

of MHPG? 

In which medical condition is 

there an increased concentration 

of VMA? 


is serotonin? 

What behavioral factors does 

serotonin alter? 

Locus ceruleus 

3-Methoxy-4-hydroxyphenylglycol 

(MHPG) 

Vanillylmandelic acid (VMA) 

Severe depression 

Pheochromocytoma → a tumor of the 

adrenal medulla 

Indolamine 

Note: Another name for serotonin is 

5-hydroxytryptamine (5-HT). 

Impulse control 

Mood 

Sleep 

Sexuality


If serotonin levels are increased, which 

behavioral factors will be improved? 

If serotonin levels are increased, which 

behavioral factors will be impaired? 

If serotonin levels are decreased, which 

behavioral factors will be impaired? 

How is serotonin synthesized? 

Where are most serotoninergic cell 

bodies located in the brain? 

Which pharmacologic agents are used 

to alter the level of serotonin in 

the brain? 

What is the primary metabolite of 

serotonin? 

In which psychiatric condition(s) is 

there a decreased concentration 

of 5-HIAA? 


is histamine? 

Which pharmacologic agents block 

the histamine receptor? 

What are side effects of the histamine 

receptor blockade? 


is acetylcholine (ACh)? 

Where is acetylcholine normally 

found in the body? 

Mood 

Sleep 

Sexual functioning 

Impulse control 

Sleep 

Note: Patient is likely to experience 

depression. 

Tryptophan is converted to serotonin by 

tryptophan hydroxylase and an amino 

acid decarboxylase. 

Dorsal raphe nucleus 

Antidepressants—eg, selective serotonin 

reuptake inhibitors (SSRIs) 

5-Hydroxyindoleacetic acid (5-HIAA) 

Alcoholism 

Bulimia 

Impulsive behavior 

Pyromania: uncontrollable desire to set 

things on fire 

Severe depression 

Tourette syndrome 

Violent behavior 

Ethylamine 

Antipsychotic drugs 

Tricyclic antidepressants (TCAs) 

Increased appetite → contributing to 

weight gain and obesity 

Sedation 

Quaternary amine 

Neuromuscular junctions


Which psychiatric conditions are 

associated with a decrease in 

cholinergic neurons? 

How is acetylcholine synthesized? 

How is acetylcholine degraded? 

Which pharmacologic agents have been 

shown to reduce the degradation 

of acetylcholine? 

What are the three primary amino acid 


Which amino acid neurotransmitter(s) 

are excitatory? 

Which amino acid neurotransmitters(s) 

are inhibitory? 

Which pharmacologic agents alter 

duration and frequency of GABA? 

Which neurotransmitter regulates 

glutamate activity? 

Which pathologic conditions may 

glutamate play a role in? 


Down syndrome 

Movement disorders 

Acetyl coenzyme A (CoA) and choline 

are converted to acetylcholine by 

choline acetyltransferase in cholinergic 

neurons 

Acetylcholine esterase (AChE) degrades 

acetylcholine into acetate and choline. 

Donepezil 

Tacrine 

Note: These agents can slow the 

progression of diseases such as 

Alzheimer disease. 

1. GABA 

2. Glutamate 

3. Glycine 

Glutamate 

GABA—primary inhibitory 

neurotransmitter 

Glycine 

Barbiturates: alter duration of GABA 

channel opening 

Benzodiazepines: alter frequency of 

GABA channel opening 

Glycine 

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? 

Which factor does endogenous 

opioids alter in research studies? 

Which neuropeptide(s) has been 

implicated in aggression and pain? 

Which neuropeptides have been 

implicated in Alzheimer disease? 


implicated in mood disorders? 


implicated in schizophrenia? 

Anxiety 

Mood 

Pain 

Seizure activity 

Temperature regulation 

Placebo effects → endogenous opioids 

are thought to play a major role in the 

placebo effects seen in research studies. 

Substance P 

Somatostatin 

Vasoactive intestinal peptide (VIP) 

Oxytocin 

Somatostatin 

Substance P 

Vasopressin 

VIP 

Cholecystokinin (CCK) 

Neurotensin 


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? 

What are the five axes used in the 

DSM-IV-TR? 

What is an important criterion 

of most DSM-IV-TR disorders? 

What strategy will help when learning 

the different types of disorders? 

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) 

The symptoms cause significant 

social or functional impairment. 

This distinguishes a disorder from 

a normal variant. 

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? 

What are the clinical hallmarks 

of psychosis? 

Significant impairment in reality 

testing (ability to distinguish real 

from imaginary) 

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? 

Name the six major primary psychotic 

disorders. 

Other than primary psychotic disorders, 

what other types of psychiatric illness 

often manifest psychotic symptoms? 

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. 

1. Brief psychotic disorder (6 months of 

symptoms) 

4. Schizoaffective disorder 

5. Delusional disorder 

6. Shared psychotic disorder 

• 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 B 12 

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? 

What are the DSM-IV-TR criteria 

for Schizophrenia? 

What are negative symptoms? 

What are considered the positive 

symptoms of schizophrenia? 

What is a “first-rank” symptom? 

How does the criterion of 

disorganized speech, (also referred 

to as thought disorder) manifest 

in schizophrenia? 

Schizophrenia. The incidence 

in the adult population is 

around 1%. 

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 

Negative symptoms (think deficits) include 

affective flattening, alienation (social 

withdrawal), alogia (poverty of 

speech), and avolition (lack of 

motivation). 

Usually this refers to the hallucinations, 

delusions, bizarre behavior, and thought 

disorder. 

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. 

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. 

X 

X Y 

W 

A B A B A B 

Normal Circumstantial Tangential 

Y 

Z 

What is meant by the prodromal and 

residual phases of schizophrenia? 

How long must you have symptoms for 

before schizophrenia can be diagnosed? 

How does schizophreniform disorder 

differ from 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. 

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. 

The duration is


Does gender affect the development 

of schizophrenia? 

What other epidemiological factors 

are correlated with increased risk 


What is downward drift? 

What is the dopamine hypothesis? 

Are there any structural brain changes 

associated with schizophrenia? 

What are the five major subtypes 


Which form tends to have the best 

social functioning? 

Which form is the least common? 

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. 

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). 

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. 

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. 

Increase in size in the lateral and 

third ventricles, generalized atrophy 

of the cortex, and frontal lobe 

abnormalities are often associated 

with schizophrenia. 

1. Paranoid 

2. Residual 

3. Catatonic 

4. Disorganized 

5. Undifferentiated 

Paranoid. They also tend to be slightly 

older at onset, and have prominent 

hallucinations and delusions, with a 

lesser component of disorganization. 

Catatonic. Prior to the development 

of antipsychotics, this form was 

more common.


What is catalepsy and waxy flexibility? 

What is the most predictive of overall 

prognosis in schizophrenia? 

Overall, schizophrenia is associated 

with repeated psychotic episodes, and 

a chronic downhill course. What 

features are associated with a somewhat 

better prognosis? 

Are patients with schizophrenia at risk 

of suicide? 

What is the primary treatment for 


What is the difference between typical 

and atypical antipsychotics? 

What is EPS? 

How do you treat EPS? 

What is tardive dyskinesia? 

How do you treat tardive dyskinesia? 

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. 

Level of premorbid function 

Abrupt onset, female gender, presence 

of mood symptoms, and old age at onset 

Yes! Over half of schizophrenics 

will attempt suicide at some point in 

their lives, and 10% will die from it. 

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. 

This includes tremor, rigidity, akathisia 

(inner restlessness), and acute dystonias 

(muscle spasm). 

Anticholinergics (eg, diphenhydramine 

and benztropine) 

Abnormal movements of the face, 

trunk, extremities, and mouth that 

may happen after prolonged exposure 

to antipsychotic medications. 

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? 

What is a potentially fatal side effect 

of antipsychotic treatment? 

How does NMS present? 

What is the first thing you should do 

if a patient presents to the ER 

with NMS? 

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. 

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%. 

Fever, muscle rigidity, altered mental 

status, and autonomic instability 

Stop the antipsychotic! Then care is 

primarily supportive. 

Other Psychotic Disorders 

What is the DSM-IV-TR criteria 

for Schizoaffective Disorder? 

What are the two types of 

schizoaffective disorder? 

How could you differentiate 

between a mood disorder with 

psychotic symptoms (eg, major 

depressive disorder [MDD] with 

psychosis or Bipolar Mania) from 

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. 

1. Bipolar 

2. Depressed 

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? 

What are some types of delusions 

that may occur in this disorder? 

What is a shared psychotic 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. 

1. Erotomanic: Someone is in love with 

patient. 

2. Somatic. 

3. Grandiose. 

4. Jealous: Wife/husband is cheating. 

5. Persecutory: Patient is being 

mistreated. 

A rare disorder where the patient 

believes the delusions of another person 

with a primary psychotic disorder. 


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 

What are the DSM-IV-TR criteria for a 

major depressive episode? 

What is anhedonia? 

What is SIG E CAPS? 

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 

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 

Loss of pleasure in all or almost all 

activities 

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) 

What is the prevalence of major 5% to 12% for men and 10% to 20% 

depressive disorder (MDD)? 

for women, with a 2:1 female to 

male ratio 

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? 

What medications can cause depressed 

mood? 

What is double depression? 

What is “postpartum onset” depression 

(aka postpartum depression, PPD)? 

What is the diagnostic criteria for 

dysthymic disorder? 

How can you differentiate dysthymic 

disorder from MDD? 

How do you treat depression 

pharmacologically? 

Thyroid dysfunction (particularly 

hypothyroidism) 

Malignancy 

Stroke (Post-stroke depression) 

Neurodegenerative disorders 

Mononucleosis 

Acquired immunodeficiency syndrome 

(AIDS) 

Syphilis 


Stroke 

Multiple sclerosis 

Lupus 

Nutritional deficiency 

Menopause 

Accutane (isotretinoin) 

Reserpine 

Beta-blockers 

Steroids (eg, prednisone) 

Methyldopa 

Interferon (used to treat viral hepatitis) 

Oral Contraceptive Pills 

This term is used when a patient meets 

criteria for both MDD and dysthymic 

disorder. 

A major depressive episode happening 

within 4 weeks of delivery (some believe 

within 12 months of delivery is still 

PPD) 

Depressed mood for a least 2 years, 

plus two more symptoms of major 

depression, but not meeting criteria 

for MDD 

Dysthymic disorder must last longer, 

but is less severe. 

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 

Brand 

Generic Name Name Side Effects Other 

Citalopram Celexa Standard Fewest medication 

(Sexual side 

interactions 

effects, nausea, 

vomiting, 

headache, anxiety, 

insomnia) 

Escitalopram Lexapro Standard Isomer of 

citalopram, very 

similar 

Fluoxetine Prozac Standard Long half-life, 

drug-drug 

interactions 

Paroxetine Paxil Standard, plus Short half-life, can 

has anticholinergic cause withdrawal 

effects that can 

symptoms (except 

cause weight gain, CR form), drugconstipation, 

drug interactions 

and sedation 

Sertraline Zoloft Most GI side Very few drug-drug 

effects 

interactions 

Abbreviations: GI, gatrointestinal. 

Are there any other antidepressants Yes, there are other antidepressants 

also considered as first-line treatment with different mechanism of action 

options? (see Table 13.2).


Table 13.2 Other Antidepressants Indicated for the Treatment of Depression 

Generic Brand Mechanism Side 

Name Name of Action Effects Other 

Bupropion Wellbutrin Unknown, likely Seizures, Contraindicated 

Zyban (for via dopamine insomnia, in patients with 

smoking and headache, seizures, 

cessation) norepinephrine nausea, bulimia, and 

vomiting, anorexia 

constipation, 

and tremor 

Used to treat 

sexual side 

effects caused 

by SSRIs 

Mirtazapine Remeron Presynaptic alpha-2- Highly Agranulocytosis 

adrenergic sedating, in 0.1% 

antagonist (↑ ↑appetite, Also used to 

norepinephrine ↑weight ↓ nausea 

and serotonin) 

also potent 

antagonist of 

5-HT 2 and 

5-HT 3 

Trazodone Desyrel Weakly inhibits Highly Used as a 

serotonin sedating, sleeping aid 

reuptake 

orthostatic 

hypotension 

Postsynaptically Uncommon 

antagonizes but can 

5-HT 2 

cause 

priapism 

(painful 

erection) 

and 

arrhythmias 

Nefazodone Serzone Similar to Headache, FDA black-box 

trazodone dry mouth, warning due 

blurred to risk of liver 

vision, failure 

somnolence, 

and 

orthostatic 

hypotension


Table 13.2 Other Antidepressants Indicated for the Treatment of Depression (Continued ) 

Generic Brand Mechanism Side 

Name Name of Action Effects Other 

Venlafaxine Effexor Serotonin and Nausea, Can increase 

norepinephrine dizziness, blood pressure 

reuptake 

sexual 

inhibitor, also dysfunction, 

inhibitor of headache, 

dopamine and dry 

reuptake at mouth 

high doses 

Duloxetine Cymbalta Similar to Nausea, dry Also indicated 

venlafaxine mouth, for neuropathic 

constipation, pain 

diarrhea, 

dizziness, 

and 

insomnia 

What are tricyclic antidepressants 

(TCAs)? 

Why are tricyclics a second-line 

treatment option? 

What are the side effects of tricyclic 

antidepressants? 

Older antidepressants (also known as 

heterocyclics) are currently considered 

a second-line treatment option. 

Greater side effects and lethality in 

overdose 

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? 

Are there any other medications to 

treat depression? 

Why are MAOIs a third-line option? 

What is serotonin syndrome? 

When does a hypertensive crisis occur 

in the context of MAOI use? 

When are MAO inhibitors particularly 

efficacious? 

Are there any other ways to treat 

depression? 

What type of psychotherapy is used 

to treat depression? 

Amitriptyline, desipramine, imipramine, 

and nortriptyline 

Yes, the monoamine oxidase inhibitors 

(MAOIs), considered third-line option. 

MAOIs are rarely used any more. 

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. 

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. 

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. 

Atypical depression (those with 

increased appetite and sleep) and 

treatment-resistant depression 

Yes, by using psychotherapy or 

electroconvulsive therapy in severe 

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


What is electroconvulsive therapy 

(ECT)? 

When is ECT used? 

What are the main side effects 

of ECT? 

What are the DSM-IV-TR diagnostic 

criteria for a Manic Episode? 


hypomania and mania? 

What is a mixed episode? 

How do you diagnose Bipolar I 

Disorder? 

It is the induction of a generalized 

seizure by applying electric currents 

to the brain. 

It is mainly indicated for patients with 

refractory or psychotic depression, but 

it can also be used for the treatment of 

mania. 

Short-term memory loss 

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 

Hypomanic episodes last 4 days or 

more and do not require hospitalization 

or involve psychotic features. In 

general, hypomania is less severe 

than mania. 

A 1-week or longer period in which 

criteria for both manic and major 

depressive episodes are met. 

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, Sedation, GI, Induces 

Carbatrol, reversible mild metabolism of 

Equetro leukopenia, itself and other 

reversible mild medications, 

increase in LFTs, decreasing its 

tremor, 

hyponatremia 

own level during 

therapy 

Associated with 

aplastic anemia and 

agranulocytosis 

Must monitor 

levels 

Lamotrigine Lamictal Rash may occur Good for 

in 10% of 

depressed state, 

individuals, may rapid cycling, 

rarely 

and mixed states 

progress to Start low and go 

Stevens-Johnson slow to avoid rash 

syndrome (rare) No level 

has been 

monitoring 

reported 

required 

Lithium Eskalith Tremor, Narrow 

nephrogenic therapeutic 

diabetes 

index, can cause 

insipidus, 

toxicity with ↑ 

hypothyroidism, sweating, 

GI symptoms, NSAIDs, or 

teratogen, 

thiazides 

weight gain diuretics 

Must monitor 

levels 

Valproic acid Depakote Rare fatal Inhibits 

hepatotoxicity, metabolism of 

agranulocytosis other 

Teratogen: folic medications 

acid antagonist (↑ their level) 

→neural tube Must check LFTs 

defects 

and monitor 

Benign elevation level 

of transaminases, 

GI side effects, 

sedation, tremor, 

alopecia, 

weight gain 

Abbreviation: LFTs, Liver function tests; NSAIDs, nonsteroidal anti-inflammatory drugs. 

100


How do you diagnose Bipolar II 

Disorder? 

Are there any drugs that induce mania? 

What is cyclothymic disorder? 

What is the prevalence of bipolar 

disorder? 

The patient has one or more major 

depressive episodes, plus one or more 

hypomanic episodes (but never any 

manic episodes). 

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. 

Cyclothymic patients meet criteria for 

dysthymic disorder and experience 

hypomanic episodes. 

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. 


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? 

What are the major types of anxiety 

disorders? 

What is the most prominent feature 

of all anxiety disorders? 

What differentiates anxiety disorders 

from healthy anxiety? 


criteria for GAD? 

Anxiety disorders 

Generalized anxiety disorder (GAD) 

Panic disorder 

Social phobia 

Specific phobia 

Obsessive-compulsive disorder 

Agoraphobia 

Posttraumatic stress disorder (PTSD) 

Acute stress disorder (ASD) 

The presence of a sense of impending 

doom or threat 

Anxiety out of proportion to actual 

threat which causes significant distress 

or impairment 

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 1:2 

GAD prevalence? 

What are important nonpsychiatric 

differentials to consider for GAD? 

What is the initial pharmacological 

treatment for GAD? 

What medications give rapid relief, 

but have significant long-term abuse 

potential? 

Substance-induced anxiety 

Substance withdrawal anxiety 

General medical conditions 

Pheochromocytoma 

Hyperthyroidism 

Electrolyte abnormalities 

Selective serotonin reuptake inhibitor 

(SSRI) 

Venlafaxine 

Buspirone 

Mirtazapine 

Benzodiazepines 

PANIC DISORDER 

What are the DSM-IV-TR criteria for a 

panic attack? 

What characterizes panic disorder? 

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 

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 1:3 

panic disorder? 

What is the age of onset of panic 

disorder? 

Is family history of panic disorders 

relevant? 

What are the most common psychiatric 

sequelae of panic attacks? 

What is the most effective psychotherapy 

for panic disorder? 

What is the pharmacologic treatment 

of panic disorder? 

What are the important nonpsychiatric 

differential diagnoses for panic 

disorders? 

What phobia may occur with 

Panic Disorder? 

Mid-twenties 

Yes. Evidence does support an 

upregulation of adrenergic output 

responsible for stimulating anxiety 

centers in the brain which predisposes 

certain people to panic attacks. 

Agoraphobia. Patients have anticipatory 

fear which prevents them from venturing 

outside alone. 

Cognitive behavioral therapy including 

relaxation techniques 

SSRIs (first-line) 

Tricyclic antidepressant (TCA), 

monoamine oxidase inhibitors (MAOIs) 

(second-line) 

Arrhythmias 

Angina 

Hypoxia 

Hyperthyroidism 

Substance-induced intoxication or 

withdrawal 

Agoraphobia 

OBSESSIVE-COMPULSIVE DISORDER 


obsessive-compulsive disorder (OCD)? 

What is an obsession? 

Presence of obsessions and/or compulsive 

behavior that are time consuming and 

cause significant distress or impairment 

of functioning 

Persistent, recurrent thoughts which 

cause irrational anxiety


What is a compulsion? 

What differentiates OCD from 

obsessive-compulsive personality 

disorder (OCPD)? 

A repetitive behavior that reduces 

anxiety—behavior may not be directly 

related to the obsession 

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 1:1 

for OCD? 

What is the age of onset of OCD? 

What common psychiatric diagnoses 

are associated with OCD? 


for OCD? 


of OCD? 

What are the important differential 

diagnoses for OCD? 

Late adolescence to early adulthood 

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. 

Cognitive-behavioral therapy 

(exposure-response prevention, 

flooding, thought stopping) 

High-dose SSRI (first-line treatment) 

Clomipramine (second-line treatment) 

Specific phobia 

GAD 

Body dimorphic disorder 

Trichotillomania 

SOCIAL PHOBIA 

What are the diagnostic criteria 

for social phobia? 

What characterizes social phobias? 

Persistent fear of social situations 

Anxiety or panic attack when exposed 

to social situation 

Avoidance or distress of feared situation 

results in functional impairment 

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? 

What is the age of onset of 

social phobias? 

What are the most common 

social phobias? 

What is the most effective 

psychotherapy for social phobias? 


of social phobias? 

What medications are effective 

for immediate relief of symptoms, 

but must be used cautiously? 

What are the important differential 

diagnoses for social phobia? 

Adolescence following childhood 

shyness 

Fear of public speaking 

Fear of public performances 

Fear of answering questions in class 

Cognitive-behavioral therapy including 

relaxation techniques 

SSRIs (first-line treatment) 

Beta-blockers 

Benzodiazepines—should be avoided in 

those with substance abuse potential 

Specific phobias 


OCD 

POSTTRAUMATIC STRESS DISORDER 

What are the DSM-IV-TR criteria for 

posttraumatic stress disorder (PTSD)? 

What is increased arousal in 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 

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? 

What differentiates PTSD from 

adjustment 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. 

PTSD involves life-threatening events 

(rape, war, etc) 

Adjustment disorders involve non-lifethreatening 

events (divorce, death of 

others) 


for PTSD? 

How is PTSD classified? 


for PTSD? 


of PTSD? 

What medication is particularly effective 

for PTSD nightmares? 

What are important differential 

diagnoses for PTSD? 

Acute PTSD: Symptoms last 3 months. 

Delayed-onset PTSD: Symptoms begin 

>6 months after the life-threatening 

event. 

Cognitive-behavioral therapy (CBT) 

and support groups 

SSRIs (first-line treatment) 

Mood stabilizers 

Prazosin (alpha-blocker) 

Acute stress disorder 

Adjustment disorder 

OCD 

Malingering 

SPECIFIC PHOBIA 

What are the symptoms of a specific 

phobia? 

Fear of specific situations 

Anxiety 

Palpitations 

Sweating 

Headache 

Restlessness


What characterizes specific phobias? 

What differentiates specific phobias 

from social phobias? 

Excessive, irrational fear of specific 

objects or situations 

Specific phobias involve fear of specific 

objections or situations not associated 

with being scrutinized. 

What is the male to female ratio for 1:2 

specific phobia? 

What is the age of onset of specific 

phobias? 

What are the most common types of 

specific phobias? 


for specific phobias? 


of specific phobias? 


diagnoses for specific phobias? 

Mostly childhood but can begin at 

anytime 

Animals 

Storms 

Heights 

Illness 

Injury 

Flooding 

Gradual desensitization 

Hypnosis 

CBT 

Benzodiazepines for certain phobias 

such as flying 

Social phobia 

OCD 

GAD 


ADJUSTMENT DISORDER WITH ANXIETY 

What is the main characteristic of 

adjustment disorder with anxiety? 

During what time period should the 

symptoms present after stressor occurs? 

When should symptoms of adjustment 

disorder with anxiety resolve? 

What are common causes of adjustment 

disorder? 

Emotional or behavioral symptoms 

associated with an identifiable stressor 

Within 3 months of initial stressor 

Within 6 months of initial symptoms if 

stressor removed 

Divorce 

Relocation 

Attending a new school


What should be ruled out before 

diagnosing adjustment disorders? 

How does adjustment disorder with 

anxiety present? 


diagnoses? 

Bereavement 

Any Axis I diagnosis 

Occupational impairment 

Social impairment 

Scholastic impairment 

Bereavement 


Acute stress disorder 

PTSD 


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? 

What causes delirium? 

While most substances of abuse can 

cause delirium with acute intoxication, 

which three are most likely to cause 

delirium related to withdrawal? 

What factors predispose to 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. 

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. 

Alcohol (delirium tremens), 

benzodiazepines, and barbiturates 

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? 

111 

A long list, including: 

Anticholinergics (including Benadryl) 


Levodopa and other dopaminergics 

Opioids 

Cardiac medications, eg, Beta-Blockers 

Many antibiotics


How common is delirium? 

Clinically, what is the hallmark 

of delirium? 

In addition to alterations in 

consciousness, what other features 

are often found in a patient 

with delirium? 

How do you test for delirium? 

How do you treat delirium? 

While treating the cause of a delirium, 

how do you manage a delirious 

patient? 

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%! 

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. 

Altered sleep-wake cycle 

Perceptual disturbance 

Impaired memory and orientation 

Nocturnal worsening of symptoms 

Psychomotor agitation 

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. 

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. 

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? 

In order to diagnose dementia, what 

must be present in addition to memory 

impairment? 

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? 

When diagnosing dementia, what other 

disorders in your differential are key 

to rule out? 

What is the prevalence of dementia? 

What is the most common type 

of dementia? 

What is the classical clinical course 

for Alzheimer disease? 

How does this differ from the course 

of vascular dementia? 

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. 

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 B 12 , thiamine, and folate 

deficiencies, and normal pressure 

hydrocephalus. 

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. 

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. 

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. 

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? 

On postmortem examination, what 

changes are normally seen in the 

brain of an Alzheimer disease patient? 

What areas of the brain show cell loss 

in Alzheimer disease? 

What class of medications is used 

to slow the progression of Alzheimer 

disease? 

Age, family history, Apo E4 allele, and 

Down syndrome 

Neurofibrillary tangles and senile 

(amyloid) plaques 

While there is also often global cortical 

atrophy, neuronal degeneration is 

classically in the cholinergic neurons 

of the nucleus basalis of Meynert. 

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 Impaired memory 

consciousness 

with normal level 

of consciousness 

Course Fluctuates within the course Usually stable within 

of a day with lucid periods 

a day 

Worsens at night 

May worsen at night 

(sundowning) 

Occurrence Most common in elderly and Increases with age 

young children 

Psychiatric Hallucinations and delusions Hallucinations and 

Symptoms may be present delusions may be 

present 

Physical Abnormal EEG Normal EEG 

findings Acute medical illness No acute medical 

illness 

Prognosis Symptoms tend to resolve with Usually progressive 

treatment of underlying cause

Cognitive Disorders 115 

AMNESTIC SYNDROMES 

How do amnestic syndromes differ 

from dementia? 

Which brain structures are affected 

in amnestic syndromes? 

Damage to mediotemporal structures 

is associated with what vitamin 

deficiency? 

Name at least four other etiologies 

of amnestic syndromes. 

In amnestic syndromes, the disturbance 

of function is isolated to memory, while 

other cognitive functions remain 

relatively intact (unlike dementia). 

The bilateral mediotemporal structures 

(eg, mammillary bodies, hippocampus, 

fornix) 

Thiamine deficiency. Often this is 

related with chronic alcohol abuse 

(Korsakoff syndrome) 

1. Traumatic brain injury 

2. Herpes encephalitis 

3. Cerebrovascular disease 

4. Hypoxia 


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 

What are the primary types 

of somatoform disorders? 

What is factitious disorder? 

What is malingering? 

What is the primary difference between 

somatoform disorders and factitious 

disorder or malingering? 

Somatization disorder 

Conversion disorder 

Hypochondriasis 

Body dysmorphic disorder 

Pain disorder 

A disease in which the patient 

intentionally feigns illness to assume 

the sick role, but with no other obvious 

motivation (aka Munchausen 

syndrome) 

Intentional feigning of illness for the 

purpose of gaining a conscious reward 

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 

Are there any physical examination 

findings which are common 

in somatoform disorders? 

No. Disease etiology must be ruled out 

in these patients; however, there is no 

medical condition that can account for 

their symptoms. 

117


What are some disorders with 

nonspecific symptoms that should 

be thought of before somatoform 

disorder is diagnosed? 

Should patients with somatoform 

disorders be told that they are 

imagining their symptoms? 

What is a good way to frame 

the possibility of a lack of general 

medical problem? 

What is a good statement to make 

when discussing the possibility 

of psychiatric treatment with a patient? 

SLE, Multiple Sclerosis, Myasthenia 

gravis, Hyperparathyroidism, Thyroid 

disturbance, Porphyria, Malignancy 

No. Supportive treatment with 

suggestions that psychotherapy may 

alleviate their distress is associated with 

a better prognosis. Remember that pain 

is a subjective experience. 

Reassurance that there is no serious 

underlying medical cause, but without 

dismissing their symptoms—this may 

alleviate some anxiety. 

“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 

Somatic complaints must begin prior 

somatization disorder? to age 30. 

What are common patterns of behaviors 

seen in these patients? 

Can the symptoms occur in the presence 

of a true medical condition? 

What is the prevalence of somatization 

disorders in the United States? 

What are risk factors for somatization 

disorder? 

What is the most common first 

manifestation of this disorder 

in women? 

These patients often have had multiple 

exploratory surgeries and visit multiple 

doctors. 

Yes, however, the complaints will often 

be in excess of what would be normally 

expected. 

0.2% to 2% in women and

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? 

What are the most common 

manifestations seen? 

What is a common presentation? 

What are common findings on physical 

examination of these patients? 

What is a common association 

with the onset or exacerbation 

of symptoms? 

What medical disorder can present 

similarly to a conversion disorder? 

Neurologic (motor and/or sensory) 

Sudden onset of blindness 

Paralysis 

Paresthesias 

Seizures 

Dramatic onset of symptoms that are 

often physiologically impossible 

Abnormalities do not have anatomical 

distribution and neurologic examination 

is normal. 

Often stressful life events precede the 

development of symptoms. 

Multiple sclerosis 

What percentage of individuals Very few—approximately 4% 

diagnosed with a conversion disorder 

in fact have a true neurological 

condition? 

Do patients with true conversion 

disorders sustain injury as a result 

of their condition? 

Are patients with conversion disorder 

distressed over their condition? 

No. Patients with sudden onset of 

blindness do not run into objects, 

and those with paralysis may still 

inadvertently move when distracted. 

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? 

What is the prognosis and duration 

of symptoms seen in conversion 

disorders? 

What is the treatment for conversion 

disorders? 

No 

Symptoms typically remit within 2 weeks, 

with favorable prognosis seen in paralysis 

and blindness, and a poor prognosis 

associated with seizures. 

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? 

Are there true physical symptoms 

seen in this disorder? 

What are the most common presenting 

symptoms seen in hypochondriasis? 

Is there a gender predominance seen 

in hypochondriasis? 

What are common associations with 

the development of hypochondriasis? 

What are common behaviors seen 

in these patients? 

Preoccupation with having a serious 

disease, despite medical reassurance 

of health status 

Yes, however, the symptoms are 

misinterpreted by the patient as being 

of a greater significance. 

Nausea 

Abdominal pain 

Chest pain 

Palpitations 

No, men and women are equally 

affected. 

Often the person has experienced 

serious illness in childhood or knows 

someone who has died or suffered 

through a serious medical condition. 

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 1% to 5% 

hypochondriasis? 

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? 

Is the defect always imagined 

by the patient? 

What are the two components of body 

dysmorphic disorder? 

What are risk factors for the development 

of body dysmorphic disorder? 

Where do these patients often present? 

What are the most common features 

viewed as defective in these patients? 

What is the most common comorbid 

psychiatric disorder associated with 

body dysmorphic disorder? 

What are some common behaviors 

seen in this disorder? 

What other diagnoses must be 

considered in the differential? 

Do surgical procedures and alterations 

tend to improve the patient’s view 

of his or her physical defect? 

What is the recommended treatment 

for body dysmorphic disorder? 

Preoccupation with a defect in physical 

appearance 

No. In some patients the defect may be 

imagined, but in others an exaggeration 

of a true physical feature may be present. 

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. 

Family history of a mood disorder or 

obsessive-compulsive disorder 

Often these patients present to 

dermatologist and plastic surgeons. 

Facial features 

Hair 

Body build 

Depression 

Excessive grooming 

Avoidance of mirrors 

Excessive exercise 

Avoidance of public activities 

Anorexia nervosa 

Gender identity disorder 

Narcissistic personality disorder 

No. These treatments tend to worsen 

the disorder, leading to intensified or 

new preoccupations with physical 

appearance. 

Antidepressants (such as selective 

serotonin reuptake inhibitors [SSRIs]) 

(only if comorbid mental illnesses such 

as depression or anxiety are present) 

and cognitive behavioral therapy


FACTITIOUS DISORDER 


of factitious disorder? 

Are patients with factitious disorder 

or malingering aware of the false 

nature of their somatic complaints? 

How is factitious disorder different 

from malingering? 

Which gender is more prevalent 

in factitious disorders? 

What occupation has the highest 

prevalence of factitious disorders? 

What disease presentations are often 

seen in factitious disorder? 

What laboratory finding would indicate 

self-injection of insulin? 

What are common behaviors seen in 

patients with factitious disorder? 

What are common histories of patients 

with factitious disorder? 

What is the appropriate treatment 

for factitious disorder? 

What is the prevalence of factitious 

disorder? 

Which gender is most commonly seen 

in factitious disorder? 

What is a well-known variant 

of factitious disorder? 

Intentional simulation of illness 

Yes. This is the distinguishing 

characteristic between factitious 

and somatoform disorders. 

The only obvious conscious goal of 

factitious disorder is to assume the “sick 

role”—there is no clear benefit or gain. 

Female 

Health-care workers 

Hematuria (from adding blood to urine 

or from the use of anticoagulants) and 

hypoglycemia (from insulin injection) 

Low C-peptide level 

Requests for analgesics 

Extensive knowledge of medical 

terminology 

Eager desire to undergo medical 

procedures and operations 

Traveling to different locations, 

hospitals, emergency rooms, etc 

Patients often have dramatic histories 

with extensive details about their 

symptoms. 

Recognition and confrontation in a 

nonaccusatory manner 

0.5% to 0.8%—very difficult to determine 

Females 

Factitious disorder by proxy (aka 

Munchausen syndrome by proxy)



of factitious disorder by proxy? 

Who is the most common 

perpetrator seen in factitious 

disorder by proxy? 

What is the treatment for factitious 

disorder by proxy? 

Intentional simulation of illness in 

another person 

A parent (most often a mother) often 

stimulating illness in her child 

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? 

How is malingering different from 

factitious disorder? 

What are common scenarios in which 

malingering is often seen? 

Which gender is most prevalent 

in malingering? 

What is Ganser syndrome? 

In what populations is Ganser 

syndrome most commonly seen? 

Intentional production of symptoms for 

secondary gain 

The goal of malingering is to obtain a 

concrete or material gain. 

Individuals wanting to avoid jail time 

or military recruitment, seeking financial 

compensation, etc 

Males 

A variant of malingering in which 

patients give ridiculous answers to 

questions in order to avoid 

responsibility for their actions 

Prison inmates 


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? 

What constitutes a personality 

disorder? 

What diagnostic criteria are common 

to all personality disorders? 

Which axis of the DSM-IV-TR 

do personality disorder 

diagnoses fall under? 

How are the personality disorders 

divided? 

Which personality disorders fall 

under cluster A? 

What is the common theme among 

cluster A disorders? 

Which personality disorders fall under 

cluster B? 


cluster B disorders? 

Personality is “the set of characteristics 

that defines the behavior, thoughts, and 

emotions of individuals,” and is 

persistent over time. 

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. 

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. 

They are Axis II diagnoses. 

Into clusters—A, B, and C 

Paranoid, schizoid, and schizotypal 

They are considered odd or eccentric 

traits. 

Histrionic, narcissistic, antisocial, and 

borderline 

They are described as dramatic, 

emotional, and erratic. 

125



cluster C? 


cluster C disorders? 

What is a good way to remember these 

clusters? 

Avoidant, dependent, and 

obsessive-compulsive 

They tend to be anxious and fearful. 

They are Mad, Bad, and Sad. 

A = Mad, B = Bad, C = Sad. 

CLUSTER A: THE MAD 

How is schizoid personality disorder 

described? 

What are the symptoms/criteria for 

schizoid personality disorder ? 

How is paranoid personality disorder 

defined? 

What are the criteria/symptoms 

of paranoid personality disorder? 

Patients have “a pervasive pattern of 

detachment from social relationships 

and a restricted range of expression of 

emotions in interpersonal settings.” 

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 

Paranoid personality disorder involves 

a “pervasive and unwarranted suspicion 

and mistrust of people, hypersensitivity 

to others, and an inability to deal with 

feelings.” 


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? 

How is schizotypal personality disorder 

defined? 

What are the symptoms of schizotypal 


What percentage of patients with 

Schizotypal Personality Disorder 

go on to develop schizophrenia? 

Psychotherapy and possibly 

antipsychotic medications to manage 

agitation and paranoia (overt delusions 

are not usually seen) 

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 

Odd thinking and speech 

Suspiciousness/paranoia 

Inappropriate/constricted affect 

Odd behavior/appearance 

Lack of close friends 

Excessive social anxiety 

10% to 20%—ie, most do not 

CLUSTER B: THE BAD 


cluster B? 


cluster B disorders? 

What other psychiatric diagnoses 

do patients with cluster B disorders 

often carry? 

How are patients with antisocial 

personality disorder usually described? 

What prior childhood diagnosis must 

have been present in order to be 

diagnosed with antisocial personality 

disorder as an adult? 

Histrionic, narcissistic, antisocial, 

and borderline 

They are described as dramatic, 

emotional, and erratic. 

Mood disorders are quite prevalent, 

as well as somatization disorders, 

and substance abuse/dependence 

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. 

Conduct disorder



antisocial personality disorder? 

What is the best treatment of antisocial 


How is borderline personality 

disorder defined? 

What defense mechanism is prevalent 

in patients with borderline personality 

disorder? 

What are the symptoms/diagnostic 

criteria of borderline 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 

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. 

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.) 

Splitting—eg, people are either all good 

or all bad. 

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? 

What developmental characteristics 

are often present in patients 

with borderline personality 

disorder? 

What is the best treatment for borderline 


What drug class should be avoided in 

patients with borderline personality 

disorder? 

How is narcissistic personality disorder 

described? 


criteria of narcissistic personality 

disorder? 

What other psychiatric conditions 

are associated with narcissistic 


Unstable relationships and mood/ 

affect lability 

Many were severely abused as children. 

Psychotherapy and mood stabilization 

with either antidepressants, 

carbamazepine, or valproate. 

Patients may also require shortterm 

antipsychotics for treatment 

of psychosis. 

Benzodiazepines, because of addictive 

potential and with overdose 

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.) 


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 

Mood disorders and other cluster 

B traits


What is the best treatment of 

narcissistic personality disorder? 

How is histrionic personality disorder 

described? 


criteria of histrionic personality 

disorder? 

What other psychiatric disorders are 

often associated with histrionic 


What is the best treatment of histrionic 


Psychotherapy (either group or 

individual) 

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.) 


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 

Mood disorders and somatization 

disorders 

Psychotherapy and antidepressants for 

underlying mood disorders 

CLUSTER C: THE SAD 

How is avoidant personality disorder 

often described? 

What other personality disorder may 

avoidant personality disorder be 

mistaken for? 

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. 

Schizoid personality disorder


How can avoidant personality disorder 

and schizoid personality disorder be 

differentiated? 


criteria of avoidant personality 

disorder? 

What other psychiatric conditions 

are often seen in patients with avoidant 


What is the best treatment of avoidant 


How is dependent personality disorder 

described? 


criteria of dependent personality 

disorder? 

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. 


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. 

Social phobia, specific phobia, and 

agoraphobia 

Psychotherapy and assertiveness 

training, SSRIs, Beta-Blockers 

Patients are passive and may let others 

direct their lives and make important 

decisions. (Think Bill Murray’s 

character in What about Bob?) 


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 


What is the best treatment for dependent 


How is obsessive-compulsive 

personality disorder described? 

How does obsessive-compulsive 

personality disorder (OCPD) differ 

from obsessive-compulsive disorder 

(OCD)? 


criteria of obsessive-compulsive 


What is the best treatment for 

obsessive-compulsive personality 

disorder? 

Depression and anxiety disorders 

Psychotherapy and assertiveness 

training, treatment of comorbid 

conditions 

Individuals have extreme perfectionist 

tendencies and inflexibility, a 

preoccupation with orderliness 

and control. 

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. 

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 

Psychotherapy



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? 

What are the four major dissociative 

disorders? 

Which conditions are included in the 

differential diagnosis of dissociative 

disorders? 

Which disorder is associated with 

an inability to remember important 

personal information? 

Which group of people is most 

likely to suffer from dissociative 

amnesia? 

What is the primary trigger for 

dissociative amnesia? 

What treatment modality is used 

for dissociative amnesia? 

What disorder is associated with an 

inability to remember important 

personal information and wandering 

away from home to adopt a new 

identity? 

Sudden memory loss of time periods, 

events, and people 

Detachment from one’s self 

Derealization 

Blurred sense of identity 

1. Dissociative amnesia 

2. Dissociative fugue 

3. Dissociative identity disorder 

4. Depersonalization disorder 


Seizure disorders 

Head injury 

Posttraumatic stress disorder 

Malingering 

Dissociative amnesia 

Young adult females 

Often follows a psychologically 

traumatic event 

Psychotherapy 

Dissociative fugue 

135


How long does it normally take for 

the amnesia to resolve in a person 

who is experiencing dissociative 

amnesia or dissociative fugue? 


for dissociative fugue? 

Which controversial disorder is 

associated with a person having 

“multiple personalities”? 

What are the DSM-IV-TR criteria 

for Dissociative Identity Disorder? 

Which gender is most likely 

to develop dissociative identity 

disorder? 

What conditions may dissociative 

identity disorder resemble? 


for dissociative identity disorder? 

Which disorder is associated with 

repeated episodes of detachment 

and unreality about one’s own body, 

social situation, or the environment 

(derealization)? 


for depersonalization disorder? 

Minutes or days; may last for years 

Supportive psychotherapy 

Hypnosis 

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 

Female 

Borderline personality disorder 

Schizophrenia 

Psychotherapy and hypnotherapy 

Depersonalization disorder 

Psychotherapy; pharmacologic 

interventions utilized for associated 

anxiety or depression 


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? 

How is tolerance defined? 

How is withdrawal defined? 


criteria for substance abuse? 

139 

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. 

Either a need for increased amounts of 

substance to achieve the same effect or 

diminished effect with use of the same 

amount 

A withdrawal syndrome characteristic 

of the drug or the same or similar 

substance is taken to avoid that 

withdrawal syndrome. 

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.


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 • Route of administration: The faster 

to what magnitude the chemical 

through the blood-brain barrier, 

rewards are felt after ingestion 

the greater the euphoria and higher 

of a drug? 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) 

What are the three important 

observations about withdrawal 

that Himmelsbach made? 

What are the four central tenets 

that must be addressed in order 

to successfully treat drug dependence? 

How should withdrawal symptoms 

be prevented/treated during 

detoxification? 

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. 

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. 

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).

Substance Abuse Disorders 141 

How can the positive reinforcement 

effects of drugs be reduced? 

How does disulfiram work? 

What side effect of opiate antagonists 

may result in compliance problems? 

What are the three major ways 

of reducing withdrawal? 

What criteria should be used when 

selecting a substitute drug for treating 

withdrawal? 

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) 

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. 

Anhedonia 

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) 

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? 

What is the basic principle behind 

detoxification? 

What percentage of patients who 

become drug-free relapse? 

What modalities have been associated 

with decreased incidence of relapse? 

What is the most likely reason 

for relapse? 

How can cravings be treated to prevent 

relapse? 

What are some of the medical effects 

of drug abuse? 

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. 

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. 

75%—most within the first year 

Joining self-help groups → providing 

a different type of peer pressure and 

reinforcement 

Cognitive therapy → helps develop 

new and different coping skills 

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. 

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. 

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? 

What are the acute symptoms of ethanol 

toxicity? 

What are the chronic symptoms 

of ethanol toxicity? 

What are the clinical manifestations 

of fetal alcohol syndrome? 

What is the most common form 

of drug dependence? 

What are the deleterious effects 

of caffeine? 

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) 

Vomiting (with risk of possible 

aspiration due to decreased mental 

status) 

Respiratory depression 

Coma 

Death 

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) 

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 

Caffeine dependence, which is seen in 

60% to 70% of the population 

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? 

What are the physiologic effects 

of cocaine use? 

What is the most likely mechanism 

of psychosis in chronic cocaine users? 


of amphetamines? 

What are the acute and chronic effects 

of amphetamine use? 


of dissociative anesthetic drugs like 

ketamine and phencyclidine? 

What are the effects of dissociative 

anesthetic use? 


of marijuana? 

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. 

Vasoconstriction 

Tachycardia 

Hyperthermia 

Hypertension 

Cardiac dysrhythmias 

Stroke 

Psychosis 

Dopamine potentiation 

Amphetamines block both the reuptake 

of dopamine and norephinephrine at 

the synapse, as well as cause the release 

of stored catecholamines. 

Vasoconstriction 

Tachycardia 

Hyperthermia 

Hypertension 

Cardiac dysrhythmias 

Stroke 

Psychosis 

Neurotoxicity 

Dissociative anesthetics work by 

blocking N-methyl-D-aspartate (NMDA) 

receptors and sigma receptors in the CNS. 

Amnesia 

Confusion 

Delusions and hallucinations 

Violent behavior 

Hyperthermia 

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? 

Where are the opioid receptors located 

in the brain and what is the function 

of each receptor? 

What are the three classic types 

of opioid receptors? 

What receptors do most clinically used 

opiates such as morphine work on? 

What endogenous peptide transmitters 

work at opioid receptor and which 

receptors do they act on? 

Describe the mechanism of action 

of opioids at their receptors: 

How do strong agonists cause 

the effects of opioids? 

How do antagonists work? 

Poor memory and motivation 

Testosterone suppression, gynecomastia 

Chronic obstructive pulmonary disease 

(COPD) 

Immunosuppression 

Low fetal birth weight 

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 

1. Mu 

2. Kappa 

3. Delta 

Mu 

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. 

Opioid receptors are G protein–coupled 

receptors with seven membranespanning 

segments. Activation of the 

receptors causes changes in cyclic 

adenosine monophosphate (cAMP), 

Ca 2+ , etc, leading to inhibition of 

neuronal excitation. 

Strong agonists have high affinity 

for the receptor and produce a 

conformational change that activates 

the receptor. 

Antagonists have high affinity for the 

receptor and do not activate the receptor.


What is the difference between strong 

and partial agonists? 

What is the difference between opiates 

and opioids? 

How do kappa and mu receptors differ? 

Which opioids/opiates are strong 

mu receptor agonists? 

Which opioids/opiates are partial 

mu receptor agonists? 

What relative of morphine without 

sedative effect is used to suppress 

cough? 

Which opioids/opiates are mu receptor 

antagonists? 

Which opioids/opiates are kappa 

receptor antagonists? 

What drug can be used as a narcotic 

reversal agent? 

Which opioids/opiates are metabolized 

by CYP2D6? 

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. 

Opiates are derived from the 

opium poppy, while opioids 

are synthetic or semisynthetic 

derivatives of opiates. 

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. 

Morphine 

Fentanyl 

Etorphine 

Heroin 

Hydromorphone 

Oxycodone 

Meperidine 

Buprenorphine 

Pentazocine 

Dextromethorphan 

Nalorphine 

Naltrexone (nonnarcotic) 

Buprenorphine 

Naltrexone (nonnarcotic) 

Naltrexone/Naloxone (aka Narcan) 

Oxycodone 

Codeine


What is the significance of being 

metabolized by CYP2D6? 

Which opioid receptor agonist does not 

work systemically and can be used as 

an antidiarrheal agent? 

What is the clinical indication for 

methadone? 

What are the symptoms of narcotic 

overdose? 

What is the route of absorption 

of ethanol in the body? 

What is the limiting factor in ethanol 

absorption? 

What is the effect of ethanol’s water 

solubility? 


of ethanol? 

What is the physiologic effect of 

ethanol’s action on GABA receptors? 

What is the physiologic effect of 

ethanol’s action on glutamate receptors? 

In drugs that are metabolized by 

CYP2D6, the active metabolite is 

morphine. 

Loperamide, which works by reducing 

GI tract motility 

Methadone is used to treat withdrawal 

from heroin while acting to decrease 

cravings and risk from associated 

lifestyle (legal, HIV, hepatitis, etc). 

In narcotic overdoses, CO 2 drive is 

reduced resulting in respiratory 

depression and cyanosis and 

diminished mental status/coma. 

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. 

Absorption of ethanol is limited only 

by the surface area of the stomach. 

Its water solubility allows absorbed 

ethanol to be distributed throughout 

the body water. 

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. 

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. 

Glutamate is a major excitatory 

transmitter in the brain, and ethanol 

inhibits glutamate causing amnesia and 

anesthetic effects and possibly reward 

effects.


What is a useful and evidence-based 

way to screen for alcohol abuse? 

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 Four standard drinks = a BAC of 0.08% 

an 180-lb man to reach the legal 

limit (0.08% blood alcohol content 

[BAC])? 

How many drinks are needed for an Three standard drinks = a BAC of 0.10% 

140-lb woman to reach the legal limit (over the legal limit) 

(0.08% BAC)? 

How is ethanol eliminated from 

the body? 

How is ethanol metabolized in 

the liver? 

What is zero-order elimination 

of a drug? 

Ninety-five percent of the ethanol 

ingested is 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. 

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 

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? 

Which metabolic process is responsible 

for the toxic effects of alcohol? 

What are the chronic effects 

of alcohol ingestion? 

What are the three types of tolerance? 

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. 

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. 

Development of tolerance 

Psychological dependence 

Physiologic dependence (this includes 

tolerance and withdrawal) 

Huge host of medical problems, 

including liver disease, cancer, etc 

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? 

What are withdrawal seizures? 

What are alcoholic hallucinations? 

What is delirium tremens (DTs)? 

What is the earliest that DTs occur? 

How is alcohol withdrawal treated? 

Minor signs occur early and subside 

within 2 days. They include anxiety, 

tremulousness, insomnia, GI upset, 

palpitations, diaphoresis, and headache. 

Tonic-clonic movements occurring from 

2-48 hours after the last drink. This may 

progress to delirium tremens (DT). 

Visual, tactile, or auditory hallucinations 

from 12-48 hours after the last drink. 

Vital signs remain normal. 

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. 

48 hours after the last drink, though 

may be longer 

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 75% 

after alcohol detoxification? 

What are the most common reasons 

for relapse in alcoholics? 

What types of treatment can be used 

to prevent relapse in alcoholics? 

Memories/conditioning 

Peer pressure 

Genetics 

Rapid reinstatement of physiologic 

dependence 

Support groups (eg, AA) 

Psychological treatment 

Pharmacotherapy (naltrexone, 

disulfiram, or acamprosate)



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? 

What are the two subtypes of Anorexia 

Nervosa? 

What distinguishes the subtypes? 

What is the biggest distinguishing 

characteristic between Anorexia 

and Bulimia? 


criteria for anorexia nervosa? 

What are the associated physical 

or biological findings in anorexia 

nervosa? 

How is amenorrhea defined? 

1. Anorexia Nervosa 

2. Bulimia Nervosa 

1. Restricting type 

2. Binge-Eating/Purging type 

The presence of either regular binge 

eating or purging behavior is Bingeeating/purging 

type. The absence of 

either is restricting type. 

In anorexia there is a refusal to maintain 

a body weight above 85% of ideal. 

Bulimic patients may be of normal 

weight. 

All of the following: 

Severe weight loss (weighs


What is lanugo? 

What is melanosis coli? 

What is a long-term risk of anorexia? 

What are some of the warning signs 

of anorexia? 

What is the typical profile of a patient 

with anorexia? 

Do patients with anorexia typically 

have coexisting disorders? 

What is the best treatment for anorexia 

nervosa? 


criteria for bulimia nervosa? 

Fine, downy body hair, especially seen 

on the trunk 

Blackened areas on the colon, seen with 

laxative abuse 

Osteopenia, Mitral Valve Prolapse, 

Amenorrhea, Electrolyte Disturbance, 

and Death 

Excessive dieting, exercise, use of 

laxatives/diuretics/enemas 

Abnormal eating habits 

Body image disorder/body dysmorphic 

disorder 

Fear of becoming fat 

Decreased libido 

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. 

Anxiety disorders are commonly seen, 

as are mood disorders and substance 

abuse. 

Nutritional therapy and psychotherapy 

including cognitive-behavioral therapy 

(CBT) can be helpful. Pharmacotherapy is 

not terribly helpful. 

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? 

What is the cause of erosion of the 

tooth enamel? 

What is parotiditis? 

What causes the development of 

calluses on the back of the hands? 

What common medical consequences 

are seen with repeated vomiting? 

What is a traumatic consequence 

of the repeated induced vomiting 

seen in bulimia nervosa? 

How can purging be accomplished? 

Do Bulimics have to vomit or use 

laxatives to meet criteria? 

What are some of the psychosocial 

features of patients with bulimia? 

What is the best treatment for 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) 

Repeated exposure to gastric acid 

secondary to induced vomiting 

Swelling or infection of the parotid 

glands, usually secondary to 

vomiting 

Scraping fingers along teeth while 

inducing vomiting 

Hypokalemia 

Metabolic Alkalosis 

Endocrine disturbances 

Growth disturbance 

Bradycardia and dysrhythmias 

Esophageal varices and/or Mallory-Weiss 

tears from repeated retching 

Induced vomiting 

Laxative/diuretic/enema use 

Excessive exercise 

No. Even excessive exercise can 

be a “purging” behavior. 

Poor self-image 

Depression and other mood disorders 

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 


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


CHAPTER 21 

Child Psychiatry 

PERVASIVE DEVELOPMENT DISORDERS 


of the pervasive development 

disorders? 

What are the pervasive development 

disorders? 


significant communication problems, 

difficulty in forming social 

relationships, repetitive behavior, 

and unusual abilities? 

What term describes the unusual 

abilities (eg, memory, calculation skills) 

that some autistic patients have? 

The onset of autistic disorder must be 

before what age? 

What is the risk of autism in 

monozygotic twins and siblings? 

The incidence of autistic disorder is 

increased in which conditions? 

What has been shown in multiple 

analysis not to be associated with autism? 

Failure to acquire or early loss of 

communication and social interaction 

skills 

Autistic disorder 

Asperger disorder 

Rett disorder 

Childhood disintegrative disorder 

Autistic disorder 

Savant 

3 years of age 

Increased risk due to genetic component 

Congenital anomalies 

Perinatal complications 

Congenital rubella 

Phenylketonuria 

Fragile X syndrome 

Tuberous sclerosis 

Vaccination 

159


Which brain abnormalities are 

associated with autism? 

Which gender is most likely to be 

affected by autism? 

Which gender is more severely 

affected with mental retardation 

in autism? 

How is autistic disorder treated? 

What is the IQ of many autistic patients? 

Which disorder is a milder form 

of autism? 

What are the primary deficits in a 

patient with Asperger? 

Which areas of functioning are normal 

in Asperger but are usually deficient 

in autistic patients? 

Which disorder is characterized by a 

decrease in social, verbal, and cognitive 

development after a period of normal 

functioning? 


of Rett disorder? 

Which gender is primarily affected 

by Rett disorder? 

What is the genetic inheritance of 

Rett disorder? 

Seizures 

Electroencephalogram (EEG) 

abnormalities 

Anatomic and functional 

abnormalities 

Males; Four times more likely 

Females 

Therapy aimed at increasing 

communication, social, and self-care 

skills 

Generally low; may have normal 

nonverbal IQ 

Asperger disorder 

Problems forming social relationships 

Repetitive behavior 

Acute interest in obscure topics 

Cognitive and verbal skills 

Rett disorder 

Stereotyped hand-wringing movements 

Poor coordination 

Impaired language development 

Loss of hand skills 

Loss of social engagement 

Deceleration of head growth 

Females 

X-linked

Child Psychiatry 161 

What happens to males affected 

by Rett disorder? 

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? 

They die before birth. 


Boys 

DISRUPTIVE BEHAVIOR DISORDERS 


of disruptive behavior disorders? 

Which disorders are classified 

as disruptive behavior disorders? 


insistent behavior that violates 

social norms, deviation from societal 

and parental rules, property destruction, 

and aggressive behavior? 

What are examples of the behaviors 

that violate social norms that are 

common in patients with conduct 

disorder? 

If a person is 18 years or older and 

still exhibits the symptoms of 

conduct disorder, which disorder 

might they have? 


persistent disobedient, defiant, 

and negative behavior toward 

figures in authority? 

What are the primary treatment 

modalities for the disruptive 

behavior disorders? 

Improper behavior; problems with 

school performance and social 

relationships 

Conduct disorder 

Oppositional defiant disorder 


Arson 

Theft 

Animal harm 

Assault 

Antisocial personality disorder 

Oppositional defiant disorder 

Psychotherapy and a Structured 

environment, sometimes 

pharmacotherapy


ATTENTION-DEFICIT HYPERACTIVITY DISORDER 


of attention-deficit hyperactivity 

disorder (ADHD)? 

Which gender is most likely to be 

affected by ADHD? 

By definition, ADHD symptoms 

must be evident by which age to be 

given the classification of ADHD? 

How long must the symptoms of ADHD 

be present to be given the classification 

of ADHD? 

Inattention 

Hyperactivity 

Impulsivity 

Impairment in multiple settings 

(eg, both school and home) 

Boys 

Before 7 years of age 

At least 6 months 

What percentage of the general child 3% to 7% 

population in the United States is 

affected by ADHD? 

What is the intelligence level of persons 

with ADHD? 

Normal intelligence 

What percentage of ADHD patients 20% 

have symptoms that persist into 

adulthood? 

What are the primary treatment 

modalities of ADHD? 

What is a non-stimulant medication 

for individuals with ADHD greater 

than the age of 6? 

Which single drug is most widely 

prescribed for ADHD? 

Stimulants—usually amphetamines 

Atomoxetine 

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? 

Tourette syndrome has a high 

comorbidity with which other 

psychiatric disorders? 

What is the primary treatment 

for Tourette syndrome? 

What is a treatment for Tourette 

syndrome that is refractory 

to medications? 


excessive and inappropriate anxiety 

concerning separation from parents, 

caretakers, and their home and 

production of physical complaints 

to avoid going to school? 

What is the most common age of 

onset in a person who presents 

with separation anxiety disorder? 

Usually 7 to 8 years of age; onset 

usually by 21 years of age 

ADHD 

Obsessive-compulsive disorder 

Dopamine-blocking antipsychotics 

(if interfering with social interactions) 

Botox (for tics) or Deep brain stimulation 

Separation anxiety disorder 

7 to 8 years of age 

Psychotherapy, especially cognitive- 

behavioral therapy 

Selective mutism 

Girls 

10 years of age 

Stressful life events 

Family and behavioral therapy 

Which treatment modalities are most 

effective in the treatment of separation 

anxiety disorder? 


a refusal to verbally communicate 

in some or all social situations in 

which the child may communicate 

with gestures? 

In which gender is selective mutism 

more common? 

Selective mutism has a poor 

prognosis if it persists after 

which age? 

What is the primary trigger for the onset 

of separation anxiety disorder and 

selective mutism? 

What is the most common treatment 

modality for selective mutism?



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? 


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? 

Which benzodiazepines are considered 

anxiolytics? 


hypnotics (used to facilitate sleep)? 

What drug can be used to reverse 

the effects of benzodiazepines? 

What is the general mechanism 

of action of benzodiazepines? 

Is there a danger in taking 

benzodiazepines during pregnancy? 

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). 

Alprazolam 

Chlordiazepoxide 

Clonazepam 

Clorazepate 

Diazepam 

Lorazepam 

Quazepam 

Midazolam 

Estazolam 

Flurazepam 

Temazepam 

Triazolam 

Flumazenil (Romazicon)—though it is 

used with caution as it can precipitate 

withdrawal seizures 

Benzodiazepines target the GABA A 

(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. 

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? 

Where does benzodiazepine 

metabolism occur? 

Which benzodiazepines skip phase 1 

and/or phase 2 of metabolism and are 

therefore safer to give to patients 

with liver failure? 

What are the symptoms of 

benzodiazepine withdrawal? 

What are the possible side effects 

of benzodiazepines? 


to be high potency? 


to be low potency? 

Which benzodiazepines are most 

commonly used for treatment 

of alcohol withdrawal seizures 

(delirium tremens)? 

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. 

In the liver 

Desmethyldiazepam 

Oxazepam 

Temazepam 

Lorazepam 

Midazolam 

Triazolam 

Anxiety 

Insomnia 

Irritability 

Delirium, Psychosis 

Weakness 

Tremor 

Seizures 

Drowsiness 

Confusion 

Motor incoordination 

Cognitive impairment 

Anterograde amnesia 

Triazolam 

Alprazolam 

Clonazepam 

Diazepam 


Oxazepam 


Lorazepam 

Diazepam

Psychopharmacology 167 

Which benzodiazepines are indicated 

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? 


of barbiturates? 

What is the mechanism of action and 

common use of Buspirone? 

Which short-acting antianxiety agent 

is used to treat insomnia? 

What is the most commonly prescribed 

class of drugs for the treatment 

of depression? 


of SSRIs? 

What are the names of commonly 

prescribed SSRIs? 

What serious side effects have a greater 

incidence associated with the SSRI 

Paroxetine? 

What caution should you take while 

using SSRIs in children and adolescents? 

Diazepam and lorazepam 

Less potential for abuse 

Higher therapeutic index 

Barbiturates target the GABA A 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. 

It is a 5-hydroxytryptamine receptor 1A 

(5-HT 1A ) (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). 

Zolpidem tartrate 

SSRIs (selective serotonin reuptake 

inhibitors) 

They work by inhibiting neuronal 

uptake of serotonin, thereby increasing 

the synaptic concentration of serotonin. 

Fluoxetine 

Fluvoxamine 

Paroxetine 

Sertraline 

Citaprolam 

Anticholinergic effects, sexual 

dysfunction, and withdrawal syndrome 

There is a black box warning about 

increased suicidal thoughts in patients 


Which SSRIs are now available 

in generic form (and may be a better 

choice for patients with a limited 

budget)? 

Why does fluoxetine and paroxetine 

have a greater association with drug 

interactions than other SSRIs? 

Why is insomnia a troubling side effect 

of fluoxetine? 

Which SSRI is most likely to cause 

gastrointestinal disturbances? 

Which SSRI is currently only 

indicated for obsessive-compulsive 

disorder? 


of bupropion (Wellbutrin)? 

What is the major indication 

for bupropion? 

What is another common indication 

for bupropion? 

What is a unique side effect 

of bupropion that should be thought 

of before prescribing it in epileptic 

patients? 

What is a common indication for the use 

of trazodone? 

What is a problematic side effect of the 

antidepressant trazodone seen mostly 

in males? 


of tricyclic antidepressants (TCA)? 

Fluoxetine (Prozac) 

Paroxetine 

Sertraline 

Citalopram 

They have greater P-450 inhibition than 

the other SSRIs. 

It causes the most central nervous 

system (CNS) activation of the 

SSRIs. 

Sertraline (Zoloft) 

Fluvoxamine 

It is thought to work mostly on dopamine 

and norepinephrine, though the exact 

mechanism is unknown. 


Smoking cessation 

It can lower the seizure threshold, 

especially in quick release formulas 

and at high doses. 

Insomnia 

Priapism (painful, persistent erection) 

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? 

Why are tricyclics used less often 

than SSRIs? 

What other syndrome are TCAs 

indicated for treating? 

What are common side effects 

of tricyclic antidepressants? 

What are the effects of TCA overdose? 

What is the most important clinical 

test in evaluating suspected tricyclic 

overdose? 

What is the treatment of acute tricyclic 

overdose? 

Which tricyclic antidepressants 

are known to have more anticholinergic 

effects? 

What are examples of other tertiary 

tricyclics antidepressants? 

Which tricyclic agent is the least 

sedating? 

Which tricyclic is prescribed for 

enuresis (bed-wetting)? 

Which tricyclic is classically prescribed 

for obsessive-compulsive disorder? 

Amitriptyline 

Clomipramine 

Doxepin 

Desipramine 

Imipramine 

Nortriptyline 

Side effects and potential for lethal 

overdose. They are still very efficacious 

medicines. 

Chronic and neuropathic pain 

Tricyclic antidepressants have 

anticholinergic effects including dry 

mouth, blurry vision, constipation, 

urinary retention, confusion, and 

memory deficits. 

Cardiac effects are the most 

dangerous—notably widened QRS, 

prolonged PR and QT intervals. 

Sedation, delirium, and anticholinergic 

effects may also be present. 

ECG 

IV Sodium Bicarbonate 

Tertiary tricyclics (eg, amitriptyline) 

Imipramine 

Doxepin 

Desipramine 

Imipramine 

Clomipramine 

Note: This is the most serotonin-specific 

tricyclic.


Which tricyclic is the least likely 

to cause orthostatic hypertension? 

What is the most common indication 

for MAOIs (monoamine oxidase 

inhibitors)? 


of MAOIs? 


prescribed MAOIs? 

What are the common side effects 

of MAOIs 

What other medication must be avoided 

in patients taking MAOIs? 

What other substance must be avoided 

by patients taking MAOIs? 

What MAO inhibitor is now available 

in a transdermal patch which does not 

require a change in diet? 

What are some pharmacologic agents 

that can cause psychosis? 

Nortriptyline 

Treatment of atypical depression 

(depression with increased sleep, 

appetite, and leaden paralysis) 

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. 

Selegiline 

Phenelzine 

Tranylcypromine 

Sedation 

Anticholinergic effects 

Orthostatic hypotension 

Cardiac conduction disturbances 

Stimulants and pseudoephedrine must 

be avoided because they can cause 


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 


Selegiline, which is also useful for 

patients who cannot swallow oral 

medicines 

Amphetamines 

Cocaine 

L-Dopa


What is the mechanism of action for 

most typical antipsychotics? 

What is the most popular of the 

biochemical theories that explain 

the development of psychosis? 

What is the most common problematic 

side effect of typical antipsychotics? 

Which of the extrapyramidal side 

effects is a flag for caution for future 

use of typical antipsychotics? 

Which typical antipsychotics have the 

most extrapyramidal effects? 

Which is the most potent of the typical 

antipsychotics? 

What pharmacologic evidence does not 

support the dopamine hypothesis? 

What is the mechanism of action of the 

atypical antipsychotic clozapine? 

What is the greatest benefit of atypical 

antipsychotics? 

What is the major side effect to beware 

of with clozapine? 

They are dopamine receptor 

antagonists. 

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. 

Extrapyramidal effects/Parkinson-like 

side effects: 

Bradykinesia 

Rigidity 

Tremor 

Acute dystonia 

Akathisia 

Note: Chronic tardive dyskinesias may 

also occur. 

Acute dystonic reaction 

Fluphenazine = haloperidol 

> chlorpromazine > thioridazine 

Note: This is correlated with 

potency/D2 blockade. 

Fluphenazine 

Atypical antipsychotics are very 

efficacious, but many work on other 

neurotransmitters and have little effect 

on dopamine. 

It acts on dopamine, serotonin, 

and acetylcholine receptors. 

They usually have fewer extrapyramidal 

side effects than typical antipsychotics. 

Agranulocytosis → necessitates weekly 

or biweekly white blood cells (WBC) 

monitoring in patients on clozapine 

therapy.


What is the biggest benefit of clozapine? 

What is the mechanism of action of the 

atypical antipsychotic risperidone? 

What are other side effects of 

antipsychotic therapy? 

What is the cause of amenorrhea 

in women taking antipsychotics? 

Which pharmacologic agents are used 

to treat acute mania associated with 

bipolar disorder? 

What agents are used for maintenance 

therapy in bipolar disorder? 

What are some of the side effects 

of lithium? 

It is efficacious for treatment. It is 

efficacious for resistant schizophrenia, 

though because of the side effects and 

monitoring it is never first line. 

It works by blocking both dopamine 

and serotonin receptors. 

Weight gain and metabolic syndrome 

Anticholinergic effects 

Antihistaminergic effects/sedation 

Amenorrhea 

Temperature dysregulation 

Neuroleptic malignant syndrome 

Blood dyscrasias 

Sexual dysfunction 

Dopamine receptor antagonism leading 

to elevated prolactin levels 

Lithium 

Atypical antipsychotics 

Valproic Acid (aka Depakote, valproate) 

Carbamazepine 


Lithium 

Valproic acid 

Carbamazepine 

Atypical antipsychotics 

Lamotrigine (Lamictal) 

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? 

What is the main drawback of using 

antipsychotics such as olanzapine 

for bipolar maintenance? 

Which anticonvulsants are used to 

treat bipolar disorder? 

What type of therapy is used for major 

depressive order that is refractory 

to treatment? 

In what other psychiatric conditions 

can ECT be used as treatment therapy? 

When does the maximum response 

to ECT usually occur? 

What is the biggest side effect of ECT? 

How can the amnesia and memory 

loss associated with ECT be 

minimized? 

None. Risk of relapse must be weighed 

against the risks of birth defects. 

Electroconvulsive therapy is likely the 

safest treatment overall in pregnancy. 

Side effects, especially weight gain 

Carbamazepine 

Valproic acid 

Lamotrigine 

Electroconvulsive therapy (ECT) 

Acute mania 

Schizophrenia with catatonic symptoms 

Depression, particularly with psychotic 

symptoms or in pregnancy 

Catatonia 

After a period of several weeks 

over which 5 to 12 treatments are 

administered. 

Memory loss (Retrograde amnesia), 

which may or may not be permanent. 

Unilateral electrode placement 

Is modern ECT different than 

Absolutely. Use of appropriate 

20 years ago? anesthesia and modern ECT techniques 

has significantly reduced side effects 

and complications. 

All possibilities considered, 

what is the most efficacious 

treatment for depression? 

ECT



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? 

What are the most important 

things to do if a medical error 

is committed? 

What should you do if a patient tries 

to give you a gift? 

When is it appropriate to refer a patient 

to another physician? 

What would you say to a patient with 

a terminal illness who wants to die? 

The relationship and trust built between 

the doctor and patient greatly enhance 

the effectiveness of care. 

Admit the mistake and apologize for it. 

Never try to cover up an error. 

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. 

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! 

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? 

A patient’s sibling asks you for 

information about their condition— 

do you give it to them? 

Can you tell information about a 

patient to someone uninvolved in 

their care? 

You see a former patient at a bar, 

whom you treated briefly 10 years ago. 

Can you ask them out on a date now? 

When is it OK to withhold information 

about an illness from a patient? 

A patient asks you to do a procedure 

that is legal, but is against your belief 

system. Must you do it? 

What is a good general approach to an 

emotional patient—be it angry, sad, 

or scared? 

What if the patient starts to cry? 

What are the steps to giving bad news? 

Yes. It’s unethical to endanger patient 

care with a possibly impaired physician. 

No. You must have formal permission 

from the patient to share their health 

information with anyone other than 

them. 

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. 

No. It is never ethical to have a 

romantic relationship with a patient, 

former or current. 

If the patient tells you they don’t want 

to know. It must be the patient that 

indicates this—not a family member. 

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. 

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.” 

Let them cry. Try to be comfortable with 

silence when appropriate. Offering a 

tissue is always a good gesture. 

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? 

How do you use an interpreter? 

Is it OK to allow a child or family 

member to act as an interpreter? 

What is patient adherence (formerly 

called “compliance”)? 

What are barriers to patient adherence? 

How might a physician make a 

treatment plan less complicated? 

What is an open-ended question? 

What is a close-ended question? 

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. 

Speak to the patient, not the interpreter. 

Speak clearly, being sure to pause 

intermittently to allow the interpreter 

to convey information to the patient. 

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. 

The degree to which the patient follows 

the advice of the treating physician 

Complicated medical regimens 

Poor physician-patient rapport 

Lack of patient involvement in the 

treatment plan 

Infrequent appointments 

Poor support structure/inadequate help 

at home 

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 

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.” 

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. 


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? 

What is Autonomy? 

What is Beneficence? 

What is Nonmaleficence? 

What is Justice? 

Of these principles, which one tends 

to take precedence in ethical questions, 

especially on the USMLE? 

What is the principle of double-effect? 

What is the classic example of 

double-effect? 

Is malpractice a crime? 

1. Patient Autonomy 

2. Beneficence 

3. Nonmaleficence 

4. Justice 

The patient has the right to make their 

own decisions regarding their care. 

The principle that physicians should be 

of benefit to their patients. 

Do no harm. 

The allocation of resources in a fair and 

just manner, including equal treatment. 

Patient Autonomy 

When an action that has a primarily 

good effect may also cause an 

unintended bad effect, but is still 

permissible. 

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. 

No—malpractice is a civil court matter. 

181


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)? 

How is a deviation from standard 

of care decided upon? 

What is the best way to avoid 

a malpractice suit? 

When can a physician become impaired? 

Is it acceptable to work with an 

impaired health-care provider? 

How does a physician’s human 

immunodeficiency virus (HIV) status 

affect his or her ability to practice 

medicine? 

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. 

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. 

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 clinical judgment is affected by 

the following: 

• Physical illness 

• Mental illness 

• Substance abuse 

No. It is the ethical duty of a physician 

to report an impaired health-care 

provider to the proper authorities. 

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? 

What is competence? 

Who is considered legally competent? 

Who is an emancipated minor? 

Can a person be competent in some 

areas and not others? 

Can a physician deem a patient 

incompetent? 

If a patient is ruled incompetent, how 

does the patient become competent 

again? 

No—it’s not acceptable under any 

circumstances. 

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) 

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 

Someone


Who may give informed consent 

for a patient? 

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? 

What is an advance directive? 

What is a durable power of attorney 

for health care? 

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). 

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. 

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. 

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? 

What is a DNR (do not resuscitate) order? 

Do DNR orders mean no interventions 

are done on a patient? 

When does a judge consent for medical 

treatment of a minor? 

Does this apply to a fetus? 

Under what circumstances can a 

nonemancipated minor receive 

treatment without the consent 

of his or her parent or legal guardian? 

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. 

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. 

No. Patients may choose to still have 

antibiotics, fluids and nutrition, or other 

“non-heroic” means depending on their 

wishes. 

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. 

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. 

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? 

Does this include artificial 

life support? 

Is removing artificial life support the 

same as physician-assisted suicide? 

When can a physician decide to remove 

life support without the consent of the 

patient or patient’s decision-maker? 

Is palliative care of the terminal patient 

the same as euthanasia? 

What is an informed consent? 

Does consent have to be written? 

Anytime, as long as they have the 

capacity to refuse the treatment, and 

the refusal is an informed refusal. 

Yes 

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. 

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. 

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. 

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. 

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? 

If a patient is homicidal, is a physician 

allowed to break patient confidentiality? 

In what other circumstances is a 

physician required to break patient 

confidentiality by law? 

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. 

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. 

• 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? 

When can a patient be “committed” 

or involuntarily hospitalized? 

If a patient is involuntarily hospitalized, 

can a physician administer any 

treatment they want? 

How do mentally ill patients receive 

treatment even if they refuse treatment? 

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. 

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. 

No. Even an involuntarily committed 

patient has the right to refuse medical 

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. 


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 

Yes—they vary, but there are out- 

of-pocket expenses for Medicare. 

What is the primary difference in 

health-care insurance coverage in the 

United States as compared to other 

industrialized countries? 

What options for insurance coverage 

are there and how do most people 

get their coverage? 

What is Medicaid? 

What is Medicare? 

What are the “Parts” of Medicare? 

Does Medicare have a premium, 

co-pay, and/or deductible? 

What is the group of people most likely 

to be uninsured or have no affordable 

available coverage? 

The United States is the only industrialized 

country without government-funded 

health care for all citizens. 

Employer-Sponsored Programs 

(most common) 

Individual Policy (self-purchased) 

Medicare 

Medicaid 

Government-funded program for 

low-income people below a certain 

income 

Government-funded program for those 

>65 years or those who are disabled or 

those on dialysis 

Part A: Hospital coverage 

Part B: Outpatient coverage 

Part C: Private supplement to A and B 

Part D: Prescription drug 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? 

What are some of the disadvantages 

of self-purchased individual 

health-care plans? 

What is “pooled risk”? 

What is fee-for-service? 

Who pays more for the same 

service—an uninsured patient 

paying out of pocket or an insurance 

company? 

What is a Diagnosis-related Group 

(DRG)? 

What two health-care costs are not 

covered by Medicare? 

Which government-funded insurance 

plan is funded completely by the 

federal government? 

What are the primary sources of funding 

for health-care insurance for US citizens? 

Which not-for-profit insurance carrier 

provides insurance for 30% to 50% 

of working citizens in all 50 states? 

The number continues to rise, but 

approximately 45 million plus people. 

It may be very difficult to qualify for 

these if you have any illnesses. They 

can also be prohibitively expensive. 

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.” 

Each service that is done is billed 

separately (eg, a doctor visit, x-ray, 

lab test, and surgical procedure are 

each charged for separately). 

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. 

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. 

1. Long-term nursing care 

2. Outpatient prescription drugs 

Medicare. Medicaid receives funding 

from the federal and state governments 

both. 

Employee benefit. 

People obtain health-care insurance on 

their own. 

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? 

Which type of health-care insurance 

plan has high premiums and does not 

impose restrictions on provider’s 

choice? 


of a health-care managed-care plan? 

What are the types of health-care 

managed-care plans? 

What is a health maintenance 

organization (HMO)? 

What is meant by a physician being a 

“gatekeeper”? 

What are preferred provider 

organizations (PPOs)? 

1. Fee-for-service plans 

2. Managed-care plan 

Fee-for-service plans 

Low premiums 

Restrictions on provider’s choice 

Health maintenance organization 

(HMO) 

Preferred provider organizations (PPOs) 

Point of service (POS) 

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. 

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. 

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? 

Which factors have contributed to the 

increase in health-care expenditures? 

During what time in a person’s life 

span is the most money spent? 

What are the most expensive 

components of health care in the 

United States (rank items from 

most expensive to least expensive)? 

The 2009 CIA (Central Intelligence 

Agency) World Factbook ranks 

United States at no. 50 out of 224— 

despite the increased spending. 

Larger percentage of elderly individuals 

Overuse of medical technology 

advances 

Medicaid and Medicare expenditures 

The last year of their life 

1. Hospitalization 

2. Physician costs 

3. Nursing home costs 

4. Prescription drugs 

5. Medical supplies 

6. Mental health services 

7. 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? 

What is hospice care? 

What are the goals of hospice and 

palliative care? 

What is “comfort care” and do hospice 

patients have to be on it? 

$35,000 to $75,000—depending upon 

nursing home level of care 

A unique type of service provided to 

people with terminal illness and a life 

expectancy thought to be


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 Approximately 70% 

illness that is due to individual 

patterns of living (eg, lack of exercise, 

poor dietary choices, and smoking)? 

What are the primary determinants 

of socioeconomic status? 

Which socioeconomic group tends 

to delay seeking health care and 

present with more progressive 

illnesses? 

Which gender is most likely to seek 

medical care? 

Which gender has the lowest life 

expectancy? 

Which group of people has the lowest 

life expectancy with regards to race 

and gender? 

Which group of people has the highest 

life expectancy with regards to race 

and gender? 

Which group of people represents 

the fastest growing segment of the 

US population? 

Education level 

Income 

Occupation 

Residence 

People of low socioeconomic status → 

due to lack of funds for health care 

Female 

Male 

Black males 

Asian women 

Elderly 

What is the percentage of health- 30% 

care costs the elderly population is 

responsible for? 

Which ethnic minority represents the 

largest percent of the US population? 

What are the leading causes of death 

in the United States, irrespective of 

age group? 

Hispanic 

Heart disease 

Cancer 

Stroke


What are the three leading causes 

of death in infants


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? 

What is incidence? 

What equation represents 

the relationship between 

prevalence and incidence? 

What happens to the prevalence 

of a disease as the duration of it is 

lengthened, assuming the incidence 

is held constant? 

Which is usually greater in chronic 

diseases—prevalence or incidence? 

Which is more useful for describing 

influenza over the course of a year— 

incidence or 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. 

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). 

Prevalence = incidence × disease duration 

P = I × D 

It would increase—use the equation. 

Prevalence is usually greater with long 

duration diseases, eg, HIV. 

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? 

What is Specificity? 

What is best for a screening test 

or to “rule out” disease (low false 

negative)? 

What is best for a confirmatory 

test or to “rule in” disease 

(low false positive)? 

What is a good mnemonic to 

remember this? 

What is positive predictive value (PPV)? 

What is negative predictive value (NPV)? 

What is the relation between sensitivity, 

specificity, NPV, and PPV? 


sensitivity, specificity, NPV, 

and PPV? 

How do sensitivity and specificity 

affect NPV and PPV? 

How does prevalence of disease in a 

population affect PPV and NPV? 

What is the best way to solve problems 

requiring the calculation of sensitivity, 

specificity, PPV, and NPV? 

The ability of a test to detect disease if it 

is present 

The ability of a test to discern one 

disease from another 

A test with a high sensitivity 

True negatives divided by all of the 

people without a disease or illness 

SPin (SPecificity rules in) and SNout 

(SeNsitivity rules out) 

The likelihood that a positive result on a 

test represents actual disease 

The likelihood that a negative result on 

a test actually represents the absence of 

disease 

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 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. 

A high sensitivity will increase NPV of 

a test, a high specificity will increase the 

PPV of a test. 

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!) 

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 

Test result 

– 

c 

d 

Sensitivity = a/(a + c) 

Specificity = d/(b + d ) 

PPV = a/(a + b) 

NPV = d/(c + d) 

a = True positives 

b = False positives 

c = False negatives 

d = True negatives 

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? 

How is specificity calculated? 

How is positive predictive value 

calculated? 

How is negative predictive value 

calculated? 

True positives divided by all of the 

individuals with a disease 

Sensitivity = a/(a + c) 

True negatives divided by all of the 

people without a disease 

Specificity = d/(b + d) 

True positives divided by all people 

with a positive test 

PPV = a/(a + b) 

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? 

What is meant by a study being 

“observational”? 

What is meant by a study being 

“experimental”? 

What is a case-control study? 

What is a cohort study? 

What are the two types of cohort studies? 

What is a prospective cohort study? 

What is a retrospective cohort study? 

A research study that starts after the 

studied disease or outcome has 

happened, and usually looks back 

for factors that led to it. 

The researcher separates subjects into 

groups and merely waits for the 

outcome in question to happen. 

The researcher separates subjects into 

groups and applies an intervention to 

one or more of those groups, hoping 

to modify the outcome. 

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). 

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). 

1. Prospective 

2. Retrospective 

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). 

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? 

What is a clinical trial? 

What are two primary characteristics 

of high-quality clinical trials? 

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. 

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. 

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? 

Name the types of bias that may be 

prevalent in a research study. 

Which bias can occur when hospital A 

admits sicker patients than hospital B? 

Which bias can occur when a disease 

or illness is detected earlier, leading 

to seemingly increased survival time? 

Which bias can occur when people fail 

to return surveys or respond to a phone 

or email survey? 

Which bias can occur when a study 

favors selecting subjects that have 

a particular characteristic or set of 

characteristics? 

Lacks bias 

Reliably Valid 

Admission rate bias 

Lead time bias 

Nonresponse bias 

Sampling bias 

Selection bias 

Admission rate bias 

Lead time bias 

Nonresponse bias 

Sampling bias


Which bias can occur if the subjects 

studied are not representative of the 

target population about which 

conclusions are drawn? 

What percentage of patients generally 

respond to placebos? 

What happens to the response rate to 

placebos in psychiatric conditions? 

What is the definition of a doubleblind 

study? 

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? 

What is reliability? 

What type of reliability is demonstrated 

when different examiners are able to 

achieve test results that are similar? 

What type of reliability is demonstrated 

when subsequent tests yield similar 

results to initial tests? 

What is the definition of validity? 

What is the definition of precision? 

What is the definition of accuracy? 

Selection bias 

Usually at least 33% of patients 

It increases in psychiatric illnesses. 

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. 

Crossover studies 

It is the reproducibility of a given test. 

Interrater reliability 

Test-retest reliability 

It determines whether a test measures 

what it is supposed to measure. 

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). 

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? 

Which measure(s) of association is used 

to evaluate cohort studies? 

Which measure(s) of association is used 

to evaluate case-control studies? 

How does our four-box method 

for calculating specificity and sensitivity 

change when calculating risk? 

Relative risk 

Attributable risk 

Odds ratio 

Relative risk 

Attributable risk 

Odds ratio 

The left heading of “test result” is 

changed to “exposure/risk factor” 

(the top heading stays the same). 

+ 

Disease state 

– 

+ 

Exposure/risk 

factor 

– 

a 

c 

b 

d 

RR = ([a/(a + b)] / [c/(c + d)]) 

AR = ([a/(a + b)] – [c/(c + d)]) 

OR = ad/bc 

a = Exposed subjects with disease 

b = Exposed subjects without disease 

c = Unexposed subjects with disease 

d = Unexposed subjects without disease 

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)? 

How is RR calculated? 

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. 

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? 

What is the definition of Attributable 

Risk (AR)? 

How is AR calculated? 

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? 

What is an odds ratio (OR)? 

How can you interpret odds ratio in 

comparison to relative risk? 

There is an increased risk of the disease 

or illness. 

If the RR is 0.5). 

or OR crosses 1? 


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? 

What is the definition of mean? 

What is the definition of median? 

What is the definition of mode? 

1. Mean 

2. Median 

3. Mode 

The average of a set of numbers 

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. 

The number that appears most 

frequently in a set of numbers. 

Using the following set of numbers, Mean = [(1 + 2 + 3 + 4 + 5 + 6 + 7 + 8 + 

what are the mean, median, and mode? 9 + 10 + 11 + 12 + 12)/13] = 90/13 = 6.923 

1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 12 Median = 7 

Mode = 12 

What is the range of a data set? 

Define normal distribution. 

What type of curve demonstrates 

a normal distribution? 

The difference between the highest and 

lowest values in a data set 

Note: The range in the data set above is 

12 − 1 = 11. 

A set of numbers in which the mean, 

median, and mode are equal. 

Mean = median = mode 

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? 

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? 

When a data set shows two humps, 

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. 

Positively skewed 

Mean > median > mode 

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? 

What is an independent variable? 

It is a quantity that changes throughout 

time. 

It is an attribute that the research 

scientist may adjust in an experiment.

Biostatistics 211 

What is a dependent variable? 

How do I remember this? 

What is the correlation coefficient (r)? 

Why is it important to take the absolute 

value of the r? 

What is the definition of standard 

deviation (σ)? 

How is standard deviation used? 

It is the outcome that is measured and 

affected by the experiment. 

The dependent variable is dependent on 

the independent variable. 

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. 

The absolute value of r will determine 

the strength of the correlation. 

It is the root mean square deviation from 

the average. The standard deviation is 

defined as the square root of the variance. 

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% 13.5% 34.0% 34.0% 13.5% 2.35% 0.15% 

−3 −2 −1 Mean +1 +2 +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 68% 

1 standard deviation from the mean? 

What percentage of data falls in 95% 

2 standard deviations from the mean? 

What percentage of data falls in 99.7% 

3 standard deviations from the mean? 

STATISTICAL HYPOTHESIS AND ERROR TYPES 

What is meant by “null hypothesis 

testing”? 

What is the null hypothesis (H 0 )? 

What is the alternative hypothesis (H 1 )? 

Which would be true if there was no 

effect in your research study? 

Which would be true if there were an 

effect in your research study? 

What is a type I (α) error? 

What is a type II (β) error? 

What is power? 

The idea that, by default, there are no 

relationships between variables. Research 

must then be done to disprove this— 

called “rejecting the null.” 

A hypothesis stating that there is no 

difference between an experimental 

and control group. (ie, variables are 

unrelated) 

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.” 

You would accept the null hypothesis. 

You would reject the null hypothesis. 

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. 

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.” 

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.


If the sample size increases, what 

happens to power? 

What is statistical significance? 

What is the probability (p) value? 

It increases. 

That the probability of an observed 

effect being due solely to chance is low 

enough that the effect is likely true. 

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 p


STATISTICAL TESTS 

What types of data are evaluated 

in statistical tests? 

What is nominal data? 

What is ordinal data? 

What is interval data? 

What is ratio data? 

What type of common statistical 

tests is used to analyze nominal or 

ordinal data? 

What types of statistical tests are used 

to analyze interval or ratio data? 


parametric and nonparametric 

statistical tests? 

What type of parametric statistical test 

determines the difference between 

the means of two groups? 

Which type of t-test evaluates the means 

of two groups at one period of time? 

Nominal 

Ordinal 

Interval 

Ratio 

It is categorical data where the order of 

the categories is arbitrary (eg, gender, 

religious beliefs). 

It is categorical data where there is a 

logical ordering to the categories 

(eg, first place winner, second place 

winner, third place winner, etc). 

It is continuous data where there is a 

set interval between values, but where 

there is no “natural” zero (eg, Celsius, 

Fahrenheit). 

It is continuous data where there is both 

a set interval between values and a 

natural zero (eg, weight, height). 

Chi-square 

t-test 

Analysis of variance (ANOVA) 

Linear correlation 

Parametric tests analyze data with a 

normal distribution. Nonparametric 

analyze data sets without a normal 

distribution. 

t-test 

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)


Which type of t-test evaluates 

the means of two groups at two 

different time periods? 

Which type of parametric 

statistical test determines the 

difference of means of more 

than two groups? 

Which type of ANOVA test 

determines the difference of 

means of more than two groups 

using only one variable? 

Which type of ANOVA test 

determines the difference of 

means of more than two groups 

using two variables? 

Which type of parametric 

statistical test determines the 

relation between two continuous 

variables? 

What are some examples of 

nonparametric tests? 

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) 

ANOVA 

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) 

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) 

Linear correlation 

Mann-Whitney U 

Wilcoxon’s



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

Index 

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 

Alcohol abuse, withdrawal (Cont.): 

hallucinations, 150 

seizures, 150 

symptoms, 150 

α (type I) error, 212 

Alternative hypothesis (H 1 ), 212 

Altruism, as defense mechanism, 27, 30 


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 

217

218 Index 

Antipsychotics (Cont.): 

therapy, side effects of, 172 

typical 

extrapyramidal effects, 171 



Antisocial personality disorder, 29, 

127–128, 161 



Anxiety disorders, 103–110 

adjustment disorder, 108–110 

agoraphobia, 103 

ASD, 103 

GAD, 103–104 


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 


for alcohol withdrawal, 150, 166 

for anxiety, barbiturates v., 167 

anxiolytics, 165 

delirium from, 111 

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 


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 


splitting, 128 


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 


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 219 

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 

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 


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 


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 Index 

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 


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 

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 221 

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 

H 0 (null hypothesis), 212 

H 1 (alternative hypothesis), 212 

Habituation, 40 

Hallucinations, 85–86 

alcohol withdrawal, 150 

illusions v., 86 

Haloperidol, 112 

Health maintenance organization (HMO), 

193 

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 Index 

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 


MAOIs, 98 

from medications, 94 


psychotherapy treatments, 98–99 

suicidal ideation, 93 

symptoms, 93 

TCAs, 97–98 

treatment for, 94–95, 95t, 96t 

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 


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 



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 223 

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 


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 (H 0 ), 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 

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 Index 

“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 


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 

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 225 

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 


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 


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 

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 


cravings, 142 

delirium and, 111 


dissociative disorders, 135 

among elderly, 21 

Himmelsbach hypothesis, 140

226 Index 

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 

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

Behavioral Science

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