UPDATED

TO
REFLECT THE NEW
DSM-V CHANGES

Paul Ciurysek, MD
 INDEX




Introduction to Psychiatric Medicine: Page 1

Behavioral & Cognitive Therapy: Page 9

Substance Abuse: Page 13
Cognitive Disorders: Page 23
Gender Dysphoria: Page 30
Mood Disorders: Page 33
Anxiety Disorders: Page 42
Schizophrenia: Page 54
Dissociative Disorders: Page 64
Somatic Symptom & Related Disorders: Page 68

Adjustment Disorders: Page 76
Impulse---Control Disorders: Page 81
Eating Disorders: Page 86
Personality Disorders: Page 93
Geriatric Psychiatry Condition: Page 99

Disorders of Sleep: Page 106

Ethics & Legal Matters in Psychiatry: Page 115

Abuse & Neglect: Page 128
Pediatric Psychiatry: Page 137
Psychiatric Pharmacology: Page 162
Biostatistics: Page 171
Ego Defenses: Page 198


INTRODUCTION TO
PSYCHIATRIC MEDICINE

1
 TOPICS:

New system of
categorization

Goal of Interviewing

Mental Status Exam

Diagnostic Tests of Psychiatry

2


CATEGORIZATION



The DSM-V has eliminated the old axis system for categorizing
psychiatry illness. We now use a non-axial documentation of diagnosis.
The new approach combines the former axis I, II, and III with separate
notations for psychosocial and contextual factors (old Axis IV) and
Disability (Old Axis V). On top of that, a strategy has been developed to
partially eliminate a diagnosis of not otherwise specified, or NOS,
whereby clinicians rate disorders along a sliding scale or continuum of
severity. This strategy allows physicians to create more appropriate
treatment plans for their patients.


INTERVIEW TECHNIQUES



The goal of all psychiatric interview techniques is to gain your patients
trust and build rapport. With trust and rapport, a patient will open up
with information to help you make a diagnosis. This is ideal as we need
a good psychiatric history, personal history, social history, and drug &
alcohol history in order to make the best possible diagnosis for our
patients.



The following is a look at the more commonly used interview
techniques, as well as the main purpose they serve in psychiatry.

3
 Rapport Building Techniques:

Empathy Expresses understanding of the patients situation.
Support Expresses concern and interest for the patient.
Validation Expresses the value of your patients feelings.


Information Gathering Techniques:

Facilitation Encourages a patient to dig deeper and elaborate on
their answers.
Open---ended question To help obtain as much information without
leading or closing potential areas of exploration.
Reflection Encourages a patient to expand on their answers by
reviewing a previous response.
Silence Helps to encourage your patients responsiveness.



Information Clarifying Techniques:

Confrontation Pointing out inconsistencies in the patients
responses and/or body language.
Direct Question Helps to elicit information as quickly as possible.
Recapitulation Helps summarize the information obtained during
interviews to ensure complete understanding.

4
 THE MENTAL STATUS EXAM



Is a thorough survey that helps to assess the patients current level of
mental functioning. With the MSE we can assess many characteristics,
including all of the following:
General presentation

Sensorium & Cognition

Speech

Mood & Affect

Thought

Perceptual Abilities

Judgment & Insight

Reliability

Impulse Control






THE MINI MENTAL STATUS EXAM



Is a faster, more superficial means by which we can assess a patients
current level of mental functioning. The following criteria are used to
perform the MMSE:
Orientation (have the patient name the current location and time)

Maximum score of 10

Language (have the patient name the object you are holding)
Maximum score of 8

5
 Attention & Calculation (have the patient subtract 7 from 100 and
continue subtracting 7s as long as they can) Maximum score of 5
Registration (have the patient repeat the names of three objects)

Maximum score of 3

Recall (recall the name of the three objects above) Maximum score
of 3
Construction (copy this design show them a triangle) Maximum

score of 1






DIAGNOSTIC TESTS USED IN PSYCHIATRY



We use psychological tests to assess a patients cognitive function, level
of achievement, personality, and psychopathology. Each test is slightly
different, and on a larger scale is used to gather information either
objectively or projectively.


Objective tests based on questions with either a correct or incorrect
answer.
Projective tests based on the psychiatrists interpretation of the
answers given.


Below is a list of the main tests used in psychiatry.

6
 INTELLIGENCE TESTS



Wechsler Adult Intelligent Scale Revised(WAIS---R): Is the most
commonly used intelligence test.
Wechsler Intelligence Scale for Children Revised (WISC---R): Is used to

measure intelligence in children 6---16.5 years of age.

Wechsler Preschool and Primary Scale of Intelligence (WPSSI): Is
used to test intelligence in children 4---6.5 years of age.





ACHIEVEMENT TESTS



Peabody Individual Achievement Test: Used in school systems to
evaluate achievement in specific subject areas.
Wide---Range Achievement Test (WRAT): Used clinically to evaluate

arithmetic, reading, and spelling skills.






PERSONALITY TESTS



Rorschach Test: Projective tests in which patients interpret ink---blots.
Minnesota Multiphasic Personality Inventory (MMPI---2): Objective
test in which the patient answers 566 true or false questions about
themselves.
Sentence Completion Test (SCT): Projective tests in which patients
complete sentences.

7
 Thematic Apperception Test (TAT): Projective test in which patients
create scenarios based on thirty pictures of ambiguous situations.





NEUROPSYCHOLOGICAL TESTS



Halstead---Reitan Battery (HRB): To detect and localize brain lesions
and determine their effects.
Bender Visual---Motor Gestalt Test: To screen visual and motor ability
through reproduction of designs.
Luria---Nebraska Neuropsychological Battery (LNNB): Used to
determine left or right cerebral dominance and to identify specific types
of brain dysfunction.

BEHAVIORAL & COGNITIVE

THERAPY

9
 TOPICS:
Systemic Desensitization
Cognitive Therapy
Biofeedback
Flooding Aversive
Conditioning Token
Economy

10
 BEHAVIORAL AND COGNITIVE THERAPIES



Systemic Desensitization Is used in the treatment of phobias.

In this technique, the feared object/situation is paired with a relaxing
stimulus, with the goal of provoking a relaxed response whenever the
feared object is encountered.


Cognitive Therapy Is used to treat mild/moderate depression,
somatoform disorders, and eating disorders.
Patients are encouraged to identify the negative thoughts they have

about themselves, and are taught to replace those feelings with positive,
self---reassuring thoughts about themselves.


Biofeedback Is used to treat headaches, hypertension, asthma,
Raynauds disease, chronic pain, fecal incontinence, and TMJ.
Patients are given ongoing physiologic information so they can
consciously control behaviors with the goal of achieving their desired
goal.


Flooding Is used I the treatment of phobias.

Patients are exposed to large levels of their feared object/situation as
a way of decreasing their sensitivity to it.


Aversive Conditioning Is used in the treatment of addictions.

The pairing of a pleasurable yet destructive stimulus is paired with a
painful stimulus, leading to the cessation of the pleasurable behavior.

11
Token Economy Is used in helping to increase the positive behavior
of a patient who is either severely disorganized and/or mentally
retarded.
Reinforcing a desirable behavior by offering a reward for performing
that behavior.

12


SUBSTANCE ABUSE

13
 TOPICS:

Important Definitions Classes of
Substances of Abuse Commonly
Used/Abused Substances Symptoms
of Withdrawal Diagnosing
Substance Abuse Management of
Substance Abuse

14


IMPORTANT DEFINITIONS






Substance Abuse: Describes a pattern of abnormal use that eventually
leads to impairment of functioning (social, physical, occupational).


Substance Dependence: Describes a pattern of abuse that leads to
patterns of tolerance, compulsive use, and withdrawal.


Substance Tolerance: A physiological adaptation that leads to an
increased need in order to experience the same result.
There is a phenomenon known as cross---tolerance, whereby the
adaptation to one drug causes tolerance of another (ex. Alcohol and
Benzodiazepines).


Substance Withdrawal: A physiological development of symptoms that
occur once a substance has been stopped after prolonged use and
dependence.

15
 CLASSES OF COMMONLY ABUSED SUBSTANCES



The commonly abused substances fall under one of four categories,
including:
Stimulants

Narcotics

Sedatives

Hallucinogens



Stimulants: Are substances that stimulate the CNS. Lead to a wide---

variety of symptoms, including:

Agitation, hyperactivity, tachycardia, loss of appetite, increased levels
of concentration.
Another name for cocaine is crack, which is smoked.

Amphetamines such as Methylphenidate are widely prescribed for

ADHD.

Commonly abused forms of Amphetamine include

Methamphetamine (Speed) and MDMA (Ecstacy).



Common stimulants include:

Caffeine (The most commonly used substance worldwide)

Cocaine (Can be snorted and/or smoked) Increase release of
certain neurotransmitters and/or decrease re---uptake. Specifically
blocks DA re---uptake.
Amphetamines (Commonly used by people who want to increase
alertness and/or concentration)

16
 Nicotine (Found mainly in cigarettes, is the most common cause of
preventable decrease in lifespan).





Narcotics: Belong to the opioid class of drugs, are commonly abused
and are commonly used in pain---management.
Include a wide---variety of pain---relieving drugs such as Morphine,

Codeine, Oxycodone, etc (ie. Opiates)

Cause respiratory depression, euphoria, and miosis.






Sedatives: Are a class of drugs that lead to depression of the central
nervous system, caused by an increase in the inhibitory
neurotransmitter GABA. The main sedatives include Alcohol,
Benzodiazepines, and Barbiturates.
Cause respiratory depression (Most worrisome with Barbiturates).

Disinhibition.

Depression of emotions.

Slowed mentation and physical performance.



Common Sedatives include:

Alcohol (Mood initially elevates, then CNS depression begins.
Associated with thiamine deficiency and a decrease in life---expectancy in
long---term users).
Barbiturates (Highly addictive, cause depression of respiration,
anxiolysis, dangerous when combined with alcohol).

17
 Benzodiazepines (Highly addictive, cause depression of respiration,
anxiolysis, dangerous when combined with alcohol).





Hallucinogens: Lead to symptoms of hallucinations, thought to be
related to the increase of available Serotonin.
Visual disturbances/hallucinations.

Auditory disturbances/hallucinations.

Panic attacks are common.

Altered/distorted perception of reality.

Psychosis



Common Hallucinogens include:

Lysergic acid diethylamide (LSD) Causes alteration in perception
of visual and/or auditory perception. Flashbacks are a common finding
in long---term LSD users.
Phencyclidine (PCP) Causes euphoria, amnesia, violent behavior,

distortion of perception, hypertension, hyperthermia, nystagmus.

18
 SYMPTOMS OF WITHDRAWAL



Stimulants: Withdrawal symptoms will be the opposite of the
symptoms seen during intoxication.
Depression of mood and/or energy levels.

Malaise

Fatigue

Increased appetite

Headache

Miosis






Narcotics: Withdrawal symptoms will be the opposite of the symptoms
seen during intoxication.
Diaphoresis

Anxiety

Parasympathetic overstimulation (sweating, runny nose, diarrhea, GI

cramping).

Mydriasis

19
 Sedatives: Withdrawal symptoms will be the opposite of the symptoms
seen during intoxication.
Tremor

Anxiety

Tactile hallucinations

Seizures

Delirium






Hallucinogens: There are usually no withdrawal symptoms seen in
patients who have stopped using a hallucinogen.







MANAGEMENT OF SUBSTANCE ABUSE



Diagnosing drug use and/or abuse is a simple matter of understanding
the main findings mentioned previously and keeping a close eye out for
them. Certain features are unique to particular drugs, which should be
well---known. The main laboratory findings for each class of drug is
outlined below, which are very important in making a definitive
diagnosis.

20
 Laboratory findings:



Alcohol: Blood---alcohol levels are elevated.

Amphetamines: Remain in the blood for 24---48hr.

Cocaine: The metabolite benzoylecgonine remains in the system for up
to twelve days.
LSD: Urine will be positive for LSD.

PCP: Will remain in the urine for up to one week. CPK levels also tend to
be elevated.
Marijuana: Can remain in the urine for up to one month in chronic

users.

MANAGEMENT

Alcohol:

Immediate Thiamine IM until levels are appropriately replenished.
Chronic Group therapy (Alcoholics Anonymous) is the best strategy
for most alcoholics.


Benzodiazepines/Barbiturates:

Immediate Hospitalize in anticipation of seizure, Flumazenil to
reverse effects.
Chronic Behavioral modification.

21
 Caffeine:

Immediate No treatment is required immediately, however tapering
dosages will help prevent a withdrawal headache.
Chronic Acetaminophen for headache as needed.






Cocaine:

Immediate Benzodiazepine, anti---psychotics, and preventative
management.
Chronic Manage withdrawal symptoms with Desipramine.



Hallucinogens:

Immediate Benzodiazepines, anti---psychotics.

Chronic No long---term management is necessary.



Marijuana:

Immediate Benzodiazepines for agitation.

Chronic Behavioral modification/therapy.



Nicotine:

Immediate Gum, patch, support.

Chronic Support groups, Bupropion.

22


COGNITIVE DISORDERS

23
 TOPICS:
Delirium
Dementia
Alzheimers Dementia

24


OVERVIEW



Cognitive disorders are characterized by deficits in normal mental
functioning, including:


Memory loss

Impaired judgment

Disorientation

Decreased mental acquity

Altered mood

Anxiety

Paranoia & Psychosis








DELERIUM



Is characterized by a patients fluctuation of consciousness, orientation,
and attention. This is due to some organic problem that affects the CNS.
Initially a patient will disorient to time, place, and person. There are
four common causes of delirium, which are:


Drug use (Alcohol, PCP, Sedatives)

CNS injuries (Trauma, Meningitis)

Systemic disease (Any organ)

25
 Drug withdrawal (Withdrawal from sedatives most commonly)

Common findings include a patient who experiences:



Hyperactive or Hypoactive behaviors

Confusion

Anxiety

Autonomic dysfunction

Sleep disturbances






Differential Diagnosis:



Many conditions may mimic delirium, including:

Depression

Dementia

Psychosis






Prognosis: Whenever there is a treatable underlying condition that is
treatable, the prognosis is good. Untreatable conditions and/or causes
usually lead to a worsened prognosis. Any untreated cases may worsen
and progress to dementia and/or death.

26


DEMENTIA



Is characterized by a gradual loss of memory and cognitive function.
There are many possible causes of dementia, ranging from treatable
diseases such as depression all the way to terminal illnesses such as
Huntingtons disease, Parkinsons disease, and HIV.


Important Information:

Dementia is most common in the elderly population (affects >20% of
those 80yr of age or greater).
More than half of all dementia cases are a result of Alzheimers

dementia.

Vascular dementia is also a common cause of dementia (Is the 2nd

MCC).



Probable Causes:

Genetics plays an important role in Alzheimers dementia.

Vascular disorders play an important role in dementia.

HIV infection plays an important role in dementia.

27


ALZHEIMERS DEMENTIA



Patients with Alzheimers dementia present with significant memory
loss and difficulty in communication, all while normal levels of
consciousness are seen. Personality changes are quite evident, and
usually take place in the form of excessive anger, paranoia, and
depression. It is important to realize that with age comes a normal
decrease in cognitive function and abilities, however these individuals
do not experience an inability to function on a day---to---day basis.
Alzheimers dementia patients will not only lose their memory and
cognition, but will have a decreased ability to function on their own on a
day---to---day basis. On a final note, it is important to realize that dementia
in the elder population often looks just like Alzheimers dementia, so a
close examination and family questioning should be undertaken.


Management of Alzheimers Dementia:



Tacrine, which is a cholinesterase inhibitor, has been shown to
improve cognition and delay the onset of symptoms in approximately
one quarter of all patients.
It is important to manage all anxiety and/or mood disorders

pharmacologically.

Lifestyle modifications such as diet, nutrition, living---arrangements,
and exercise should all be addressed.

28
 Prognosis:



Upon onset of symptoms, the average age of survival is
approximately eight years.

29


GENDER DYSPHORIA













30

GENDER DYSPHORIA



This is a new class of diagnosis for the DSM-V. There is great emphasis
of the concept of Gender Incongruence rather than simple cross-
gender identification. It was confirmed that gender identity disorder
(a DSM-IV classification) was neither a sexual dysfunction nor a
paraphilia.

In order to diagnose Gender Dysphoria, a group of physicians
(Endocrinologist, Sexual health expert) must take part in management
of the patient. There are separate criteria for children, adolescents,
and adults, where a child with a strong desire to be of the opposite
gender or an insistence that he/she is of the opposite gender is
necessary, but not sufficient enough to make a diagnosis. This means
that diagnosis of a child is much more restrictive and conservative than
it will be in an adolescent or adult.

31






















32








MOOD DISORDERS

33
 TOPICS:
Major Depressive Disorder
Bipolar Disorder
Dysthymic Disorder
Cyclothymic Disorder

34
 MAJOR DEPRESSIVE DISORDER



Major depression is characterized by episodes of severely depressed
mood, lasting for at least two weeks at a time. The major symptoms of
depression are a loss of interest in things usually enjoyable to a person.
Lifetime prevalence for men is 5---12% and for females is 10---20%.
Diagnosis requires a major depressive episode that lasts at least two
weeks.


While that is the major finding, there are a variety of possible signs and
symptoms associated with depression, including:


S Sleep disturbances (Hypersomnia, Hyposomnia) often patients
will complain of early---morning awakening and the inability to fall back
asleep.
I Interest loss (Loss of usual interests. Loss of ability to feel pleasure
is known as Anhedonia).
G Guilt (Patients often feel excessive guilt over things out of their
control or things they shouldnt feel guilty about).
E Energy loss (Patients have a noticeable decrease in energy).

C Concentration (Patients lose their ability to concentrate).

A Appetite changes (A decrease in appetite is more common,
although often patients will have hyperphagia during depressive
episodes).
P Psychomotor activity (Mainly a loss of cognitive functioning).

35
 S Suicidal ideation (As many as 65% of patients who are depressed
will consider harming themselves, with approximately 10---15%
attempting suicide).

Depression also presents with the following related symptoms:



Psychosis Depression in addition to psychosis, includes delusions
and/or hallucinations in rare circumstances.
Somatic Symptoms Patients will complain of a range of internal
pains, which can lead to the onset of hypochondriasis.


Seasonal Affective Disorder: A common sub---type of depression that is
limited to the winter season. These patients respond very well to
exposure to ultraviolet light.





Depression is often seen concurrently with other medical issues,
including:


Endocrine disorders: Thyroid disorders (hypothyroidism) look like
depression.
Nutritional deficiencies: Diets low in healthy fats can predispose a
patient to depression.
Neurologic disorders: Parkinsons disease, Huntingtons disease, and
other neurologic diseases tend to lead to depression. Not only is there
an underlying organic cause, but patients who are aware of the severity
of their disease tend to become depressed.

36
 Pharmacology: Many different drugs tend to cause depression (Beta
blockers, Anti---hypertensives)
Viral illnesses: HIV/AIDS, influenza, etc.

Psychiatric disorders: Schizophrenia, anxiety, drug use and abuse, and
other somatoform disorders are common causes of depression.

Bereavement commonly overlaps with MDD. Bereavement will
typically last 1-2 years, and is recognized as a severe psychosocial
stressor that may precipitate MDD in those who are susceptible (ie.
Family history or history of MDD)





Management of Depression: Today, the group of SSRIs are the 1st line
in pharmacologic management of major depression. In addition to
medication, psychotherapy is a major part of therapy.


SSRIs The main side---effects associated with SSRIs are a decreased
sex---drive and anorgasmia.
Heterocyclic anti---depressants Strongly anti---cholinergic and
sedative.
MAOIs Less favored because there is a high---risk of hypertensive
crisis (When patient eats foods high in tyramine wine, cheese, red
meat).


Refractory cases or cases that are not responsive to medication should
be considered for ETC, which is an induction of a generalized seizure
that lasts 25---60 seconds.

37

Side---effects of ETC Retrograde amnesia, lasting no more than six
months.
Contraindication Increased intracranial pressure.

38
 Other important information regarding depression:



If untreated, major depressive episodes will usually resolve within
six months.
Risk of suicide is greatest when patient has started taking anti---

depressants, because they start to gain the energy to take action.

It is within a physicians jurisdiction to admit a patient who is suspect
of having suicidal ideation, who is unable to take care of him/herself, or
doesnt have a proper support system to care for them.







BIPOLAR DISORDER



Bipolar 1 disorder is characterized by alternating episodes of mania and
major depression. Bipolar 2 disorder is characterized by alternating
episodes of hypomania and major depression. Often times, patients will
present while in the depressive phase of bipolar disorder. Taking anti---
depressants with bipolar disorder will often precipitate the manic phase
of the disease. Untreated manic episodes will usually resolve within
three months.

39
 Signs & Symptoms of mania include:



Increased energy

Lack of need to sleep

Feeling of grandiosity

Racing thoughts

Loss of inhibitions



This is a dangerous state because patients tend to act recklessly, often
spending absurd amounts of money and/or engaging in sexually risky
behaviors.





Management of Bipolar Disorder:



Lithium, Carbamazepine, and Valproic Acid are effective drugs.

Lithium has a very small therapeutic window, thus we have to
constantly check blood---Lithium levels.
Main side---effect of Lithium is nephrogenic diabetes insipidus.

40
 DYSTHYMIA & CYCLOTHYMIA



Dysthymia is characterized by mild to moderate depression, most of the
time, with no firm beginning or end.
Cyclothymia is characterized by episodes of hypomania and

mild/moderative depression.



** These condition cannot be diagnosed until symptoms have been
present for at least two years.


Management:

Dysthymia The treatment of choice is therapy (Cognitive and/or

Psychotherapy).

Cyclothymia Psychotherpy + Anti---depressants are the treatment
modality of choice.

41


ANXIETY DISORDERS

42
 TOPICS:
Generalized Anxiety Disorder
Panic Disorder
Phobias

Obsessive---Compulsive Disorder


Post---Traumatic Stress Disorder

Separation Anxiety Disorder

Selective Mutism

43
 OVERVIEW OF ANXIETY DISORDERS



Anxiety disorders are characterized by an outward manifestation of
internal fear, exhibited by both physical and emotional symptoms.
Common manifestations of anxiety, regardless of type, include the
following:


Tremor

Diaphoresis

Tachycardia/tachypnea

Dizziness

Mydriasis

Syncope

Neuropathies

GI disturbances



Common causes of anxiety include:

Neurotransmitter abnormality (GABA, 5---HT, NE, E)

Nutritional abnormalities

Substance use/abuse

Endocrine disorders

Hypoglycemia

44
 The main anxiety disorders, according to the DSM---IV include:

1 Generalized Anxiety Disorder

2 Panic disorder

3 Phobias

4 Obsessive---Compulsive disorder

5 Post---traumatic stress disorder






GENERALIZED ANXIETY DISORDER



Generalized anxiety disorder is characterized by symptoms of anxiety
that last at least six months. These patients do not have any particular
source of anxiety, but are anxious about all aspects of life. GAD is more
common in women, with half of all cases beginning in childhood and/or
adolescence.


Half of all patients with GAD will display chronic symptoms that rise and
fall throughout their lives. The other half of patients typically resolve
within a few years of having the disease. One of the most worrisome
complications of GAD is the patients risk of becoming addicted to
Benzodiazepines, which are a staple in patient management.

45
 PANIC DISORDER



Panic disorder is characterized by panic attacks that occur at random
times. Patients often describe these attacks as heart---attack---like, where
an impending fear of death is a main symptom. These attacks occur
approximately twice per week and last approximately ten to thirty
minutes. No longer do we associated panic attacks with agoraphobia.


The following are the important characteristics of panic disorder:

Mean age of onset is twenty---five, more common in females.

There is a strong genetic component to the disorder.

Is usually chronic, although stressful times of life may present with
more episodes.


Management:

Acute treatment may involve benzodiazepines.

Chronic treatment involves SSRIs.

Cognitive therapy is a staple of effective treatment.

46
 PHOBIAS



The two main phobias include Specific Phobia and Social Phobia. A
specific phobia is an irrational fear of a known object and/or situation
(ex. Spiders, Heights). Since the specificity of the phobia is known,
patients will go to great lengths to avoid the trigger. Social phobia, on
the other hand, is an exaggerated fear of social and/or environmental
situations. Because the patient fears being in public, they tend to avoid
going into public places or social situations.

IMPORTANT: The DSM-V states that patients do not have to recognize
the irrationality of their phobia in order to make a diagnosis.


Specific phobias are seen in 5---10% of the population, and is seen
equally in men and women.
Those with phobias often incur repercussions such as loss of job,
failing out of school, and failure to keep friends.
Treatment of phobias is exposure therapy, whereby we introduce a

patient to the subject of fear and desensitize them of the fear.






OBSESSIVE---COMPULSIVE DISORDER



Obsessive---compulsive disorder (OCD) is characterized by a repetitive,
intrusive feeling, thoughts, and obsessions, which lead to a build---up of
anxiety that is only relieved by performing a repetitive action. This
disorder most commonly begins in childhood, and is seen in 2---3% of the
general population. There is a strong genetic component.
47
 Common obsessions seen in OCD include:

Counting

Checking and re---checking

Decontamination

Order



A major key to diagnosing a patient with OCD is that they have insight to
the irrationality of their disease. Those with OCD personality disorder
do not see irrationality with their behavior.





Potential Causes of OCD:

Serotonin is thought to be strongly linked to OCD, and as such, SSRIs
are an effective treatment modality. Other anti---depressants acting on 5---
HT will also help patients with OCD.
Often times, a life---stressor is a common precipitant of OCD.



Important Links:

Depression is commonly seen in OCD patients.

OCD is commonly associated with other behavioral disorders such as:

Anorexia, Bulimia, Anxiety disorders, and OCD personality disorder.

Hoarding disorder (newly added to DSM-V), described as persistent
difficulty discarding or parting with possessions due to a perceived need to
save them. Severe distress is associated with discarding items.



Prognosis Treatment will significantly improve 33% of patients,
moderately improve 50%, and likely be ineffective in the remaining.
For those patients who do not see improvement with treatment, further
48
deterioration will likely occur.

49
 POST---TRAUMATIC STRESS DISORDER



Post---traumatic stress disorder (PTSD) is seen after a traumatic event
has taken place. These events are often life---threatening or life---altering.
Recurring memories and/or dreams of the event(s) lead to the
development of the disorder. Diagnosis can only be made when
symptoms are present for at least one month, beginning at least 4
weeks after the traumatic event.

IMPORTANT SIDE-NOTES: Acute Stress Disorder & Adjustment
disorder (these are closely related to PTSD, thus should be considered
as part of the overall discussion).

Acute Stress Disorder: Refers to the symptoms following a traumatic
event from 2 days 4 weeks post-trauma (remember PTSD diagnosis is
made 4 weeks after the traumatic event).
Adjustment Disorder: Considered a stress response syndrome. This is
now considered a conceptual framework for a group of disorders that
represent a simple response to life stressors (traumatic or non-
traumatic).


DSM-V suggest 4 major symptom clusters for PTSD:

1. Re-experiencing the event (spontaneous memories of the event)
2. Heightened arousal (sleep disturbance, aggressiveness/recklessness)
3. Avoidance (external reminders of the events)
4. Negative thoughts & mood/feelings






50







Management:

SSRIs

Benzodiazepines acutely (not a long---term solution, they have
increased risk of abuse).
Group therapy



Prognosis Half of patients will continually have symptoms, while the
other half will recover completely within approximately three months.




SEPARATION ANXIETY



** This is now categorized as a regular anxiety disorder (not isolated to
pediatrics)

When patients are attached to their parents beyond what is considered
normal, separation anxiety is diagnosed. The worry experienced is that
something terrible will happen to the main caregivers (usually the
parents).


Main Signs & Symptoms:

Trouble sleeping at night (ie. Nightmares, insomnia)

51
 Somatic symptoms when separated from caregivers (ie. Nausea,
Vomiting, Diarrhea, etc)


Management: Desensitization therapy, exposing them to the problem
and decreasing their worry.



SELECTIVE MUTISM

Moved into the category of Anxiety Disorders with the DSM-V.
Characterized by a sudden incapability to speak in someone who can
otherwise speak normally. Commonly children will remain silent despite
increasing their risk of social isolation, shame, or punishment.

Usually co-exists with other conditions such as:
Shyness
Social anxiety

Characteristics of Selective mutism:
Failure to speak in social situations (ongoing basis)
At least 1 month in duration
Interferes with occupational or educational experiences
Not due to lack of language comprehension, knowledge, etc.
Does not improve with age (typically)



52
Management:

For younger children:
Stimulus fading is commonly employed

53


SCHIZOPHRENIA

54
 TOPICS:
Characteristics
Signs & Symptoms
Sub---Types
Differential Diagnosis
Management
Medication Side---Effects

55
 CHARACTERISTICS



Schizophrenia is one of the most debilitating mental disorders we deal
with in psychiatry. It is characterized by patterns of disturbing
thoughts, behaviors, and speech. Patients tend to show a loss of touch
with reality when undergoing a psychotic episode, yet can demonstrate
being in touch with reality during the prodromal and residual phases.
Often times, schizophrenic patients are those in society with a strange
appearance, poor grooming, and social withdrawal.


According to the DSM-V, the criteria for diagnosis include:

Abnormalities in one or more of the following five domains:

1. Delusions
2. Hallucinations
3. Disorganized thinking
4. Grossly disorganized or abnormal motor behavior
5. Negative symptoms





Prodromal Signs & Symptoms:

Social withdrawal from friends, family, and social activities.

Behavior is quiet, passive, irritable, angry.

Physical complaints are common.

New interests in things such as: Religion, Philosophy, the Occult.



Positive vs. Negative Symptoms:

Positive Symptoms are symptoms demonstrating excessive
functioning, such as Delusions, Hallucinations, Agitation, Strange

56
Behavior, excessive talking. Positive symptoms respond exceptionally
well to traditional anti---psychotic treatment regiments.

57
 Negative Symptoms are deficits in functioning and include things
such as Thought Blocking, Flattened Affect, Poor Grooming,
Amotivation, Social Withdrawal, Cognitive Disturbances. Negative
symptoms are not as responsive to traditional treatment modalities, but
do respond well to atypical anti---psychotics such as Risperidone,
Clozapine, Olanzapine, and Quetiapine.







Signs & Symptoms of Psychosis: During an acute psychotic phase,
thought disorder is seen in addition to alterations in Perception, thought
content, thought processes, and form of thought, which include:


Delusions Falsely held beliefs that do not follow logic or reason, are
not shared by society as a whole. The most common type is a delusion
of persecution.
Echolalia Mimicking words spoken by another person.

Hallucinations False sensory perceptions of auditory or visual
stimuli. May also be tactile, gustatory, olfactory, or visceral
hallucinations.
Ideas of Reference Is a falsely held belief that one is the subject of
attention by others (often believe they are the subject of media
scrutiny).
Impaired Abstraction Ability Difficulty in differentiating the

qualities of objects or relations despite normal intelligence.

58
 Loose Associations Shifting of ideas from one subject to another in
an unrelated or partially related fashion.
Loss of Ego Boundaries Lack of knowing where ones mind and body

end and those of others begin (feel as though they are one with others).
Neologisms Invention of new words that are nonsensical.
Tangentiality Turning a logical response into a long, drawn---out,
pointless tangent.
Thought Blocking Acute stoppage in the normal thinking process
because of an onset of hallucinations.
Perseveration Repeating a thought over and over.

Word Salad Saying combinations of words that have no relation to
one---another.





SUB---TYPES



There are five main sub---types of schizophrenia, which include:

Paranoid [delusions of persecution, seen in older patients, has better
functioning patient than the other sub---types].
Undifferentiated [contains characteristics of more than one sub---

type].

Catatonic [bizarre posturing, stupor, muteness, extreme excitability].

Disorganized [poorly organized, inappropriate emotional responses,
disinhibition, seen more commonly in those < 25 years of age].
Residual [previous schizophrenic episode with residual but non---

psychotic symptoms].

59
 DIFFERENTIAL DIAGNOSIS



It is important to understand the list of potential causes of psychosis, as
they should be ruled out before making a diagnosis of schizophrenia.
The list below outlines the possible causes and/or alternate diagnoses
of schizophrenia.


Brief Psychotic Disorder Symptoms of psychosis that occur for
more than one day but less than one month.
Schizophreniform Disorder Psychosis and/or residual symptoms

that last anywhere between one month and six months.
Schizoaffective Disorder A mood disorder + symptoms of
schizophrenia (note: Mood disorder must be present for the
majority of the disorders duration)
Delusional Disorder Fixed, long---term non---bizarre or bizarre
delusions and/or thought disorders.
Schizoid Personality Disorder Patient is socially withdrawn but
there are no symptoms of psychosis.
Schizotypal Personality Disorder Odd behavior and thought
patterns without psychosis.
Psychosis due to medical condition Symptoms of psychosis that
occur as a result of an underlying medical illness.
Borderline Personality Disorder Severe mood swings, anger,

dissociation, low---level psychosis that lasts very little time.

Drug---induced Psychosis Seen commonly with LDS, PCP, cocaine,
amphetamines.

60
 MANAGEMENT



Management for schizophrenia is best approached with
pharmacological and psychological mediums. Pharmacological
treatment involves using typical and/or atypical anti---psychotic agents.
The mechanism of action of these drugs involves lowering Dopamine
levels in the brain.


Typical Anti---psychotics: Work by blocking the D2 receptors.

Classic examples are Haloperidol and Chlorpromazine.

Haloperidol has the highest tendency of causing extrapyramidal side---

effects.

Long---term management must include psychotherapy.

Improvement is seen in approximately 70% of all patients.

Typicals are most effective against positive symptoms of
schizophrenia.


Atypical Anti---psychotics: Work by blocking the D4 receptor and acting
on the Serotonin levels in the brain.
Clozapine is the drug least likely to cause extrapyramidal side---effects.

Clozapine has a tendency to suppress the bone marrow, thus we me
keep an eye on the CBC to ensure agranulocytosis hasnt occurred.
Other atypical anti---psychotics are Risperidone, Quetiapine, and

Olanzapine, they cause fewer hematologic and neurologic effects.

61
 Some patients are non---compliant, which makes them ideal candidates
for long---acting depot forms of the medication. These are administered
every four weeks intramuscularly.





MEDICATION SIDE---EFFECTS



High---potency drugs (namely Haldol and other typicals), tend to cause
greater extrapyramidal side effects. Examples are below:


Akathisia: is a subjective feeling of restlessness.

Acute dystonia: is slow and prolonged muscle spasms.

Pseudoparkinsonism: Parkinson---like movements.

Tardive Dyskinesia: Writhing movements of the head, neck, and
tongue.
Neuroleptic malignant syndrome: High fever, confusion, diaphoresis,
hypertension, muscular rigidity, renal failure.


Low---potency drugs (namely Chlorpromazine), tend to cause less
extrapyramidal side---effects and tend to cause more anticholinergic side---
effects and anti---histamine effects.


Other common side---effects:

Weight gain

Sedation

Jaundice (caused by hepatic problems)

62
 Endocrine abnormalities

Galactorrhea

Impotence

Amenorrhea

Decreased sex---drive

Hematologic dysfunction (Agranulocytosis, leukopenia)

Photosensitivity

Blue---gray skin discoloration (caused by Chlorpromazine)

Ophthalmologic effects caused by Thioridazine and Chlorpromazine






PROGNOSIS



Typically, schizophrenia is a life---long disease that waxes and wanes.



Prognosis is better when:

Onset is later in life

Patient has good social relationships, including marriage

Has mood symptoms

Female gender

Has positive symptoms

Has few relapses

63





























DISSOCIATIVE DISORDERS

64
 TOPICS:
Dissociative Amnesia
Dissociative Fugue
Dissociative Identity Disorder
Depersonalization Disorder

65
 DISSOCIATIVE AMNESIA



Characterized by an inability to recall important information about
oneself. Is an uncommon condition that is seen more commonly in
women and/or young adults. Often, if the amnesia began after a
stressful event, it resolves over time. A Dissociative Fugue is now
a specifier of dissociative amnesia, and not its own separate
diagnosis.


Management: Attempt at uncovering the stressor or trauma that

caused the amnesia in addition to long---term psychotherapy to deal with
any underlying issues.





DISSOCIATIVE FUGUE



Characterized by an inability to remember important information about
oneself, in addition to leaving home and taking on a new identity. The
patient is unaware of the new assumed identity. Is rare and is
associated with a history of excessive alcohol use. Is now a specifier of
dissociative amnesia, and not an actual diagnosis in and of itself.





DISSOCIATIVE IDENTITY DISORDER



Characterized by having at least two different personalities, also known
as Multiple Personality. The majority of patients are women, where
one personality is the dominant personality. This condition is usually
66
 associated with some underlying struggle and/or early traumatic event
in their life. Is often associated with childhood sexual abuse/incest.
Identity transitions may be observed by others and/or self-reported,
which is a new diagnostic factor in the DSM-V. Look for gaps in this
patients everyday life, not only with respect to traumatic events that
precipitated the disorder.





DEPERSONALIZATION DISORDER



Characterized by recurring and persisting feelings of detachment from
self, social situation, or environment. This disorder often occurs in
patients with other psychiatric conditions such as depression, anxiety,
histrionic personality disorder, borderline personality disorder, and
schizophrenia.

67
























SOMATIC SYMPTOM
DISORDER

68
 TOPICS:

Somatic Symptom &
Related Disorders

69
 SOMATIC SYMPTOM DISORDER



Somatic symptom disorder (SSD) is characterized by distressing
symptoms or symptoms that lead to significant disruption of normal
everyday functioning. They may also lead to disproportionate
thoughts, feelings, and behaviors regarding those symptoms. The
patient must be persistently symptomatic for at least 6 months to
make a diagnosis of SSD.

Previously, somatization disorder, hypochondriasis, pain disorder,
and undifferentiated pain disorder fell into the Somatoform disorder
category these have all been removed with the DSM-V. Many of the
findings associated with these old disorders are now going to prompt
a diagnosis of SSD. No longer are a variety of complaints from 4
different systems required as part of the diagnosis, rather the somatic
symptoms must be distressing and disruptive to daily life.

Another key change to this category is the fact that previously the
symptoms of somatoform disorders were required to be medically
unexplainable, where their symptoms could not be linked to any
organic cause. Now, symptoms may or may not be medically
explainable.

70


Diagnostic Criteria:
One or more somatic symptoms that are either distressing or result
in significant day-to-day impairment
Excessive thoughts, feeling, or behaviors related to the somatic
symptoms or associated health concerns as manifested by at least one
of the following: 1. Disproportionate and persistent thoughts about
the seriousness of ones symptoms. 2. Persistent high level of anxiety
about health or symptoms. 3. Excessive time and energy devoted to
the symptoms or health concerns.
The same symptoms need not be present continuously, but
symptoms must be persistent in some form or another for at least 6
months



Management:

Individual and/or group therapy, in addition to relaxation
techniques, are the most effective modalities of treatment
pharmacological measures are usually not the first line of treatment.










71
 HYPOCHONDRIASIS & ILLNESS ANXIETY DISORDER

Since hypochondriasis is no longer an individual disorder, patients
are now diagnosed with Somatic Symptom Disorder. The main
reasons for the change are that labeling a patient as a hypochondriac
often disrupted a strong patient-physician relationship.


CONVERSION DISORDER
(Functional Neurological Symptom Disorder)

Diagnostic criteria of FNSD is as follows:
One or more symptoms of altered voluntary motor or sensory
function
Incompatibility between the symptoms and recognized
neuro/medical conditions
Symptoms or deficit not better explained by another medical or
mental disorder
Causes significant distress or impairment in social, occupational,
or other functional areas.

Specific symptoms may include:
Weakness or paralysis
Abnormal movement (tremor, myoclonus, gait disorder)
Swallowing symptoms
Speech symptoms (slurred speech, dysphonia)
Seizures
Sensory loss / anesthesia
72
 Special sensory deficits (olfactory, auditory, visual)


Acute vs. Persistent: Acute when symptoms last < 6 months,
persistent if symptoms last > 6 months.
Also important to specify whether a psychological stressor is
present



FACTITIOUS DISORDER



Patients with factitious disorder are pretending to have an illness
and/or inducing an illness in order to obtain medical attention.
Factitious disorder imposed on another (previously known as
Factitious disorder by proxy) is seen whenever a caregiver, often a
parent, fakes or induces an illness in a child so they can obtain medical
attention. Those in the medical field are most likely to fake an illness
because they know the main signs and symptoms, with the most
commonly faked symptoms being GI, GU, cardiac, or dermatological.


Factitious disorder imposed on another is always considered child
abuse, and thus must be reported to the appropriate authorities.
Often, patients have a history of illness that resulted in their
enjoyment of being cared for.
School, work, and/or relationships often suffer as a result of the
patients preoccupation with the illness.

Willingness to undergo invasive and unnecessary procedures or

73
medications in order to confirm the seriousness of the illness.


PAIN DISORDER

The new criteria for pain disorder take into account patients who
have purely psychological pain, patients who have medical causes
of pain, and/or a combination of both. Because it is often difficult to
determine whether pain is psychological or not, we no longer class
them separately.

74


75


ADJUSTMENT DISORDER

76
 TOPICS:
Characteristics
Sub---Types
Management

77
 CHARACTERISTICS



Adjustment disorder is seen whenever someone responds in a negative
way to a change in their life. Those who undergo some sort of stressful
event will experience either a normal grief reaction or a maladaptive
reaction.


Normal Grief Is the normal response seen whenever someone
undergoes a change and/or stressful event in life. Patients in this
category can function normally.
Maladaptive Response Leads to an adjustment disorder, acute
stress disorder, or brief psychotic disorder. Patients in this category
cannot function normally.





Adjustment Disorder In the DSM-V, this category has been
reconceptualized as a stress-response syndrome. It is no longer a strict
diagnosis, rather a diagnosis explored when a patient doesnt meet the
full set of criterion for other disorders. Typically a patient with an
adjustment disorder expresses a depressed mood, symptoms of anxiety,
or conduct disturbances.


Normal Response Seen when psychological discomfort follows a
stressor, however no impairment is seen in ones life.


Normal Grief Reaction A strong emotional response after a loss of
something or someone very close to them.

78
 Acute Stress Disorder A disorder whereby there are multiple
psychological symptoms seen within the month of the stressor (2
days 4 weeks). These symptoms last two days to four weeks after
stressor, after which a diagnosis of PTSD should be explored.

Reactive Attachment Disorder There are 2 sub-divisions of
reactive attachment disorder, which is based upon old DSM-IV sub-
types: Reactive attachment disorder and Disinhibited social
engagement disorder.
Reactive Attachment Disorder: incompletely formed preferred
attachments to caregiving adults. Patients demonstrate a dampened
positive affect towards caregiver.
Disinhibited Social Engagement Disorder: more closely resembles
ADHD, whereby children typically have bonded attachments to
caregivers.

79






MANAGEMENT



Supportive therapy is the management of choice, helping the patient
adapt to the stressful even as well as give them tools to cope with the
new changes. Group therapy is often effective, as it gives those with the
disorder an empathetic environment (highly effective). Anytime
patients suffer from anxiety, depression, or insomnia in addition to the
adjustment disorder, it is recommended to treat pharmacologically.


Short---term Lasts no longer than six months after the stressor.
Long---term Lasts longer than six months after the onset of the
stressor.

80
























IMPULSE CONTROL DISORDERS

81
 TOPICS:
Intermittent Explosive Disorder
Kleptomania
Pyromania
Trichotillomania
Pathological Gambling
Internet Gaming D/O

82
 INTERMITTENT EXPLOSIVE DISORDER



Is a disorder characterized by a period whereby the patient loses self---
control and attacks another person. There is usually no cause for these
attacks. Is seen more commonly in men as a result of a decrease in
serotonergic activity.


Treat with SSRIs

Usually worsens until middle---age is reached

Patients often have unhealthy relationships






KLEPTOMANIA



Is a disorder where patients have the impulse to take things without
paying for them. The action is not done in anger or defiance, but is due
to the lack of impulse control.


Seen most commonly in those with concurrent bulimia nervosa (up
to of patients).
Usually due to a dysfunctional upbringing.

SSRIs and aversive conditioning are the treatment modalities of
choice.
The condition is chronic and usually ends only when a patient is

caught and incarcerated.

83
 PYROMANIA



Characterized by ones impulse to start fires (repetitively). A patients
desire to start fires often puts them into careers whereby they have easy
access to fires.


Is more common in males.

Usually seen in those with childhood problems.

SSRIs are the management of choice

When started in childhood there is a good prognosis, when started in
adulthood there is a poor prognosis.





TRICHOTILLOMANIA



Characterized by a patients impulse to pull out their hair, resulting in
hair loss.


More common in females.

Usually onset in childhood.

Precipitated by stress and/or depression.

SSRIs are the management of choice.

Is usually a chronic condition.

84
 PATHOLOGICAL GAMBLING



AKA Gambling Disorder. Characterized by an overwhelming need to
gamble. This usually leads to loss of financial stability and therefore
trouble with family, friends, and work.


Associated with a troubled childhood, ADHD as a child, and major
depressive disorder.
Is usually chronic and lifelong.

Gamblers anonymous is the treatment modality of choice.



INTERNET ADDICTION DISORDER



IMPORTANT NOTE: Internet addiction disorder is not listed in the DSM-V,
although it is currently a topic of study among the behavioral/psychiatric
world, and will likely be included in the next release.

85


FOOD AND EATING DISORDERS

86
 TOPICS:
Avoidant /
Restrictive Food
Intake Disorder

Anorexia Nervosa

Bulimia Nervosa

Obesity

87
 IMPORTANT CHARACTERISTICS



The DSM-V has made significant changes to the food & eating disorders
umbrella because many patients were diagnosed in the past with NOS
conditions, as they did not fit into an Anorexia or Bulimia Nervosa
diagnosis. It was found that many of the NOS patients actually had a
Binge-Eating disorder, and thus it has been added to the spectrum of
food & eating disorders. Patients with eating disorders often have
particular patterns of behavior, which are important for physicians to
recognize. Some of the important behavioral characteristics include:


They have a normal appetite.

They go to extreme measures to avoid gaining weight.

They have distortions of their body image.

Females almost always have menstrual irregularities due to the
suppression of the hypothalamic---pituitary axis.





Eating Disorder Information:

They are almost always seen in females (10:1 F:M).

The most likely time of onset is late adolescence.

Those who are higher achievers are most likely to develop an eating
disorder.
Eating disorders are rare in societies where food is not abundant.

Onset usually follows a stressful event in ones life.

88

BINGE EATING DISORDER:
Previously known as an eating order not otherwise specified, the
diagnosis is often times now a binge-eating disorder. It is defined by
recurring episodes of eating large amounts of food in a short period of
time (greater than the average person would consume), even when the
patient is not hungry.

The condition is associated with marked personal distress. And while it
is a much less commonly diagnosed condition, it can be quite severe
and leads to significant physical and psychological trauma.

Diagnostic criteria:
More than one binge-eating session per week over a 3-month period
Significant distress encountered after each episode

Management: Talk Therapy


ANOREXIA
NERVOSA



Patients have an overwhelming fear of gaining weight, thus they take to
extraordinary measures in order to lose weight or avoid gaining weight.
Patients have abnormal views of eating, usually taking odd behaviors
when faced with food (cutting into small pieces, dividing food groups,
etc).


Physical Characteristics of Anorexia:

89
 Lanugo (thin hair all over the body).

Loss of > 15% of bodyweight.

Amenorrhea.

Metabolic acidosis.

Anemia



Management:

Initial management involves helping restore the patients
electrolytes.
Family therapy may be needed if there are family dynamic problems.

Gaining weight to bring them to a healthy bodyweight is required.

Behavioral therapy is the cornerstone of management.



Anorexia re---feeding Syndrome:

Seen 2---3 weeks after initial management, patients present with
severe hypophosphatemia
Give IV phosphate replacement.

90
 BULIMIA NERVOSA



A disease whereby patients binge (eat excessively) and purge (vomit
after meal), in order to maintain a low bodyweight. Most of the time,
bingeing is done in secret. Patients have a poor self---image and are
overly concerned about weight gain.


Important Characteristics of Bulimia Nervosa:

Patients usually have a relatively normal bodyweight.

Knuckle abrasions, enamel erosions, and esophageal damage is
commonly seen in these patients.
Parotid gland inflammation is common.

Electrolyte abnormalities.

Menstrual abnormalities.



Management:

Behavioral therapy is the cornerstone of management.

Family therapy may be required if there are family dynamic
problems.
SSRIs are also commonly used to suppress the urges to binge and
purge.

91
 OBESITY



Obesity is an epidemic in North America, with more than 25% of all
people being overweight. Obesity is defined as a bodyweight that is >
twenty pounds overweight.


Increased Risks Associated With Obesity:

Hypertension

Cardiovascular disease

Diabetes

Musculoskeletal issues



** Obesity is more common in those in lower socioeconomic classes.



Management:

Commercial diets are usually only effective in the short---term, with
most people re---gaining all lost weight within five years.
Long---term weight loss is best achieved with a sensible diet and
exercise plan.

92


PERSONALITY DISORDERS

93
 TOPICS:
Cluster A Personality Disorders
Cluster B Personality Disorders
Cluster C Personality Disorders

94
 INTRODUCTION



A personality disorder is diagnosed whenever someones pattern(s) of
behavior are beyond what society deems as normal behavior. Those
with personality disorders will make other people uncomfortable in
some way or another, at which point treatment is usually sought.


Characteristics of Personality Disorders:

Patients usually have little insight into their disorder.

Patients only seek help when they are prompted to do so by others.

Patients do not have disabling symptoms, just disturbing symptoms.

Disorders must be present by early adulthood






CLUSTER A PERSONALITY DISORDERS



These disorders encompass behavioral patterns that are peculiar,
fearing of social relationships, and usually have a familiar or genetic
association with psychotic illness.


Paranoid Are distrustful and suspicious of others, and attribute the
responsibility for their own problems to others.
Schizoid Patients have a long---standing pattern of voluntary social
withdrawal, there is no psychosis seen.
Schizotypal Patients have an odd/peculiar appearance, have an odd
thought pattern/behavior, and have magical thinking.

95
 CLUSTER B PERSONALITY DISORDERS



Patients with Cluster B personality disorders are overly emotional,
dramatic, and behave in an inconsistent pattern.


Histrionic Patients are emotional, sexually provocative, and
theatrical. They have trouble maintaining intimate relationships due to
this unstable behavior.
Narcissistic Patients have a sense of entitlement and believe they are
better than others. They dont empathize with others and always put
the blame on others. They are overly sensitive to criticism.

Antisocial Patients do not conform to social norms, often breaking
the law, harming others, and lacking any remorse for these behaviors.
Conduct disorder is a pre---cursor to antisocial personality disorder.
Borderline Patients behave erratically and with impulse. They often
engage in self---harming behaviors and experience episodes of sub---
psychotic behavior.

NOTE: Oppositional defiant disorder, while often discussed alongside
anti-social personality disorder, is not a precursor to its development.
The characteristics of ODD include: Angry/irritable mood,
argumentative/defiant behavior, and vindictiveness (Thus, the
condition consists of both emotional and behavioral symptoms)











96
























CLUSTER C PERSONALITY DISORDERS



Patients with Cluster C personality disorders are overly fearful or
anxious.


Avoidant Patients are overly sensitive to rejection, socially
withdrawn, and have excessive feelings of inferiority.

97
 Dependent Patients will allow others to make decisions for them,
and often wont do anything without consent from another. Often their
self---confidence is very low.
Obsessive---Compulsive Patient is overly concerned with order and
cleanliness. Patients feel as though things must always be perfect, and
become annoyed when they arent. They are also very stubborn.





Management:

The only personality disorder in which we use medications is
Borderline personality disorder, where anti---psychotics and anti---
depressants are commonly helpful.
Medications can be used when patients are overly anxious and/or
depressed.
Psychotherapy is useful for patients with personality disorders.

Personality disorders are usually life---long and are non---curative.

98


GERIATRIC PSYCHIATRY
CONDITION

99
TOPICS: Aging/Changes of
Increased Age Death &
Bereavement
Depression in the Elderly

100
 AGING



Life Expectancy:

The average lifespan in the United States is 75.5 years.

Women life approximately seven years longer than men.

Caucasians tend to live between six to eight years longer than African

Americans.

The most important factor affecting life expectancy is genetics.






Things that change with increased age:

Blood flow decreases (to brain, heart, kidneys, GI tract).

Bone mineral density decreases (mainly in post---menopausal
women).
Vision and hearing acquity decreases.

Taste sensation diminishes.

Fatty accumulation increases.

Muscle mass decreases.

Temperature regulation is diminished.

Brain size/weight decreases.

Memory capabilities decrease.

Plaques develop in the brain (worse in dementia).

101
 Things that tend to lengthen lifespan:

Education (those with more education tend to live longer and stave---

off dementia).

Marriage.

Continued physical fitness.






DEATH AND BEREAVEMENT



Bereavement is a persons emotional response to the loss of a loved one.
There are five unique stages to the process of grieving, all of which are
eventually encountered during the grieving process. All stages are not
necessarily experienced in the particular order mentioned below:


Denial: Patients refusal to accept what has happened.

Anger: Patient demonstrates feelings of anger, which may be directed
towards themselves or others.
Bargaining: Making a deal with a supernatural power in order to
reverse the problem (undoing).
Depression: Normal depressive symptoms being.

Acceptance: Person accepts the situation.

102
 There is often times an overlap between normal grief and depression. It
is important to explore the patients response to the loss and determine
if they are in fact experiencing normal grief or pathological grief.


Normal Grief:

Sadness without depressive symptoms.

Mild weight loss, sleep disturbances, and guilt.

Illusions of seeing the deceased.

Patients make an attempt to return to normal activities of life.

Severe symptoms resolve within two months.



** Group therapy is a great strategy for helping the grieving to cope with
their loss.


Pathological Grief:

Depressive symptoms

Significant weight loss, sleep disturbance, and guilt.

Considers/attempts suicide.

Symptoms last for more than two months.

Moderate symptoms may last more than one year.

103
 DEPRESSION IN THE ELDERLY



Depression is the most common mood disorder seen in the elderly
population. Often times, depression in the elderly is a result of the
losses acquired with old age, such as:


Death of a loved one (Depression as a result of death of a loved one lasting
1-2 years is now what is required to make a diagnosis of bereavement)

Diminished health.

Loss of their ability to work (Either retirement or forced retirement).



Depression in the elderly often looks just like Alzheimers dementia,
therefore it is important to always inquire about depression before
jumping to a conclusion of Alzheimers disease. Delirium is also
commonly seen in the elderly, which is often a result of conditions such
as:


Nutritional deficiencies

Physical illness

Medication side---effects

104
 Management of depression in the elderly:



SSRIs are safe and effective for the treatment of depression.

TCAs are used in refractory cases, however it is important to have
patients use anticholinergic medications at nighttime, as to prevent falls
associated with the side---effects.
MAOIs are not generally indicated in the elderly population because

of the increased risk of hypertensive crisis.

105


DISORDERS OF SLEEP

106
 TOPICS:

Normal Sleep

Common Causes of Sleep Disorder
Common Sleep Disorders
Pediatric Sleep Disorders
Less Common Sleep Disorders

107
 NORMAL SLEEP



There are a few important stages of sleep, which are divided into three
general sections. The awake phase, the non---dreaming stages of sleep,
and the dreaming phase of sleep. The EEG is the ideal tool used for
characterizing the different phases of sleep, which are outlined below.


Stage: Awake

Beta waves, associated with active mental concentration.

Alpha waves, associated with eyes closed while awake.



Stage 1: Theta waves

Approximately five---percent of time is spent in this stage.

Is the lightest stage of sleep.

Respiration, pulse, and blood pressure decrease.

May see episodic body movements in this stage.



Stage 2: Sleep spindles & K---complexes

Approximately forty---five percent of time is spent in this stage (the
greatest amount of time in any stage).


Stage 3 & 4: Delta waves

Considered slow---wave sleep stage.

Approximately twenty---five percent of time is spent in this stage.

Is the deepest, most relaxing stage of sleep.

108
 Is a common stage of certain disorders (Sleepwalking, Enuresis,
Night Terrors).


Stage: REM

Approximately twenty---five percent of time is spent in this stage.

Time spent in REM decreases with age, decreases with ETOH

intoxication.

Is the dreaming phase.

Increased pulse, blood pressure, and respiration.

Complete relaxation of skeletal muscle.

Penile and clitoral tumescence occurs in this stage.

REM latency (time until first REM cycle) takes ninety---minutes on
average.
REM periods occur for ten to twenty minutes every ninety---minutes
throughout the night.
REM rebound is a phenomenon whereby a person lacking REM

sleep with catch---up the following night.

109
 Proper sleep requires increased levels of certain neurotransmitters,
including:


Serotonin: Increased 5---HT is needed to increase the time spent
sleeping as well as delta wave sleep.
Dopamine: Increased dopamine levels tend to decrease sleep time.
Norepinephrine: Increased NE will decrease the total sleep time and
the overall time spent in REM sleep.





COMMON CAUSES OF SLEEP DISORDERS



The two main categorical causes of sleeping disorders include Physical
causes and Psychological causes.


Physical Causes:

Medical conditions (Endocrine disorders, pain disorders).

Withdrawal of sedatives (ETOH, benzodiazepines, opiates).

Excessive use of stimulants (Caffeine, Amphetamines).



Psychological Causes:

Bipolar disorder

Major depressive disorder

Anxiety disorders (specific, general)

110
 COMMON SLEEP DISORDERS



There are two main categories of sleep disorders, they include:

Dyssomnias

Parasomnias



Dyssomnias: Are characterized by disruption in the quality and
quantity of sleep. Major dyssomnias include:
Insomnia (Trouble falling and staying asleep)

Difficulty falling asleep at least 3x/week for 1 month

Often a sign of impending depression/anxiety

Hypersomnolescence disorder (excessive sleepiness despite at least 7hr
of sleep and/or prolonged sleep time (>9hr) that is non-restorative and/or
difficulty being fully awake after abrupt awakening.

Narcolepsy (Experience sleep attacks 3x/week for at least 3 months)

Short REM latency

Hypnagogic/hypnopompic hallucinations

Sleep paralysis (lasts for a few seconds)

Sleep apnea (Central and Obstructive)

Central is caused by a lack of respiratory drive (elderly)

Obstructive (most common) due to obstruction


Sleep-Related Hypoventilation (episodes of decreased respiration
associated with elevated levels of C02)

Circadian Rhythm Sleep-Wake Disorders (persistent or recurring
pattern of sleep disruption that is primarily due to an alteration of the
circadian system or to a misalignment between the endogenous circadian
rhythm and the sleep-wake schedule required by an individuals physical
environment or social/professional schedule)

111
 Parasomnias: Are characterized by physiological or behavioral
changes associated with a lack of sleep. Major parasomnias include:
Sleepwalking (Begins in childhood, no conscious recollection of

walking while sleeping)

Sleep terrors (Awakening with terror, no recollection)

Nightmare disorders (Repetitive, frightening dreams that
cause nighttime awakening)
Non-REM sleep arousal disorder (recurring episodes of
incomplete awakening, often accompanied by sleepwalking
and/or sleep terrors)
REM Sleep Behavior Disorder (repeated episodes of arousal
during sleep associated with vocalization and/or complex motor
behaviors)
Restless Leg Syndrome (urge to move the legs, usually
accompanied by or in response to uncomfortable and unpleasant
sensations in the legs)
Substance/Medication-Induced Sleep Disorder (Severe and
obvious sleep disturbance occurring during or soon after
substance intoxication or after withdrawal from exposure to a
medication NOTE: The substance must be one capable of
causing a disturbance)
Other Specified Insomnia Disorder (any situation that is
characteristic of insomnia disorder, leading to impaired social or
occupational disturbances, yet not meeting the full criteria of
other insomnia disorders)
Unspecified Insomnia Disorder (any situation characteristic
of insomnia that doesnt meet the full criteria for insomnia
disorder or any of the disorders in the sleep-wake disorder
112
diagnostic class.

113


LESS COMMON SLEEP DISORDERS

Menstrual---Associated Syndrome:

Hypersomnia that occurs pre---menstrually.



Circadian Rhythm Sleep Disorder:

Sleep/awake patterns that occur at inappropriate times of the day.



Kleine---Levin Syndrome:

Recurring periods of hypersomnia and hyperphagia that last one to
three weeks.
Seen most commonly in adolescent boys.



Sleep Drunkenness:

A genetic condition whereby patients have significant trouble waking
up, despite getting adequate sleep.

114


ETHICS & LEGAL

MATTERS IN PSYCHIATRY

115
 TOPICS:
Confidentiality
Informed Consent
Impaired Physician
Reportable Illnesses
Ethics & AIDS/HIV
Advanced Directives
Right To Die
Malpractice

116
 CONFIDENTIALITY



Physicians are required to keep confidentiality in the majority of cases,
however are not required to do so when the threat of hard is made to
themselves or others.


Confidentiality can be broken in the following circumstances:

If you suspect the patient may attempt suicide (always ask a patient if
they are considering suicide).
If you suspect child or elder abuse.

If you suspect or hear that there is a threat to anothers safety.



If you feel that you must break confidentiality, take the following
actions:
Notify the appropriate authorities.

Admit the patient to the appropriate hospital setting.

Ensure that anybody who is in danger is notified (Tarasoff decision)






INFORMED CONSENT



Informed consent requires you to inform your patient of a few specifics
before they can give you consent to a procedure.


Patients must be informed of the following:

The condition at hand.

117
 The ideal treatment and any alternative treatments.

Benefits and/or risks of the procedure as well as the benefits and/or
risks of not having the procedure.
The expected outcome if consent is not given.

That the patient can reverse his/her decision at any time before the
start of the procedure.


Important To Keep In Mind:

Should always get written consent via signature.

Any findings during surgery that are non---emergency require another
informed consent.
Family members cannot give consent unless they are the immediate

next of kin (in cases where the patient cannot give consent).

You are not obliged to give any information to family members

(reversed if the patient gives consent).






Informed Consent In The Case Of Minors:

The primary caregiver/parent is the only person who can give
consent to the management of a minor.
If a minor is at risk of danger and the parents/caregiver cannot be
located, you can proceed without consent.
When a parent/guardian refuses to allow life---sustaining treatment
for a minor, you can get a court order in order to proceed (ie. If they
refuse treatment for religious reasons).

118
 When is Parental Consent Not Required?

For contraceptive prescriptions.

For STD management.

When there is an emergency.

For the management of drug and/or ETOH dependence.

For the care of a pregnancy.



What Constitutes An Emancipated Minor?

They are married.

They are caring for their own child.

They are supporting themselves financially.

They are enrolled in the military.





A CASE OF AN IMPAIRED PHYSICIAN



There are commonly encountered situations whereby a colleague is
incapacitated in some way, shape, or form. Some of the most common
ways you might encounter an impaired physician are:
Mental Illness

Physical Illness

Drug/ETOH Abuse

Age---related Illness

119
 What is required of you when a colleague is impaired?

As a licensed physician in the United States, you are legally and ethically
obligated to report this person. The two main reasons why this is a
necessity are:
To ensure no patient is at risk of negligence.

To ensure the physician gets the appropriate help.






REPORTABLE DISEASES

120
 Hepatitis C,acute
Hepatitis C,past or present
H VInfection (AIDS has been reclassified as H V Stage III}
Innuenza -associated pediatric mortality
Invasive Pneumococcal Disease
Legionellosis
Listeriosis
Lyme disease
Malaria
Measles
Meningococcal disease
Mumps
Novel innuenza A virus infections
Pertussis Plague
Poliomyelitis,paralytic
Poliovirus infection,nonparalytic
Psittacosis Q
fever
Rabies,animal
Rabies,human
Rubella
Rubella,congenital syndrome
Salmonellosis
Severe Acute Respiratory Syndrome-Associated Coronavirus Disease

121
List courtesy of the CDC, 2012 Nationally Reportable Diseases.

122
 ETHICS & AIDS/HIV



Due to the significant mortality associated with acquiring HIV/AIDS,
there are often issues faced when a physician is not comfortable in
interacting with this patient. The following is a list of common
scenarios that will help clarify what is and is not expected of a physician.



A physician refuses to treat an HIV---positive patient? Is this ethically
right?
No, ethical principles mandate that a physician treats this patient

despite the risks posed.



A physician is pricked by the same needle that went into an HIV---

positive patient. Is it right for him/her to demand an HIV test?

Yes, the physician should be tested in order to maintain their safety
and the safety of others. This is however not a legal requirement.


Your colleague is HIV---positive, should you be referring patients to
this HIV---positive physician?
Yes, as long as the physician is competent and is taking the
appropriate protective precautions then there is no ethical dilemma in
this situation.

123
 Your HIV---positive patient is putting her husband at risk of infection,
should you tell him?
Yes, if a patient is having unprotected sex in this situation then it is

your responsibility to inform him of his wifes HIV status. If condoms
are being used then you are not obligated to say anything. Initially, you
should try to convince your HIV---positive patient to disclose her HIV
status to her husband.




ADVANCED DIRECTIVES



The Advanced Directive is a legal statement of instruction, indicating
what should be done in the case of an emergency situation. Two forms
of the advanced directive include the Living Will and the Durable Power
of Attorney.


Living Will:

A document whereby the patient states what he/she wishes to be
done in case he/she becomes unable to give directions.
If a living will is in place, no other persons wishes can overrule the
wants and wishes of the patients living will.


Durable Power of Attorney:

A document whereby a patient designates another person to
represent them in case there is a need for medical decisions.

124
 In case of DPA, nobody else can act as the decision---maker except that
person who is designated.




THE RIGHT TO DIE



The right to die is a tricky issue because sometimes the rules do not
quite make sense to all physicians. However, there are a few clear cut
rules that can make the topic much easier to understand.


A patient who is competent has the right to refuse lifesaving
treatment for him/herself, for any reason, even if death is likely to
occur.
A parent/guardian/primary caregiver cannot refuse treatment for a
minor under their care, for any reason. In an emergency situation, a
physician has the right to act in the minors best interest without
permission from the caregiver or the courts. In a non---emergency
situation, a court---order must be obtained before treatment is initiated.
A pregnant woman has the right to refuse any and all treatment, even
if that means the fetus will be injured or die. The patient must be
competent in order to make this decision.
A competent patient has the right to stop artificial life---support, even
if this will result in death.

125
 Important legal issues as it pertains to right to life:



In order to be deemed legally competent to accept or refuse medical
treatment, a patient must first fully understand the risks/benefits of the
treatment, as well as the likely outcome that would result if they refused
the treatment.
Minors are not deemed competent unless they are emancipated.

When a patients competence is in question, a judge will have to make
the final decision as to whether they are in fact competent or not.
Mental retardation and/or other illnesses do not always immediately

deem a patient incompetent to make their own decisions.








MALPRACTICE



Occurs whenever a physician causes harm to a patient as a result of not
following the standards of practice. The four Ds of malpractice are as
follows:
Dereliction (A deviation from normal standard of care).

Duty (Of an established doctor---patient relationship).

Damages (Injury caused by physicians negligence).

Directly (Meaning damages are not caused by other factors).

All FOUR Ds must be met in order to ensure a successful lawsuit.

126
 As a result of a malpractice suit:

Patients receive Compensation or Punitive damages as a result of a
successful lawsuit.
Compensation is the most common type of award, which is a financial
reimbursement.
Punitive damages are punishments given to the physician on behalf
of the patients lawsuit. This is not a financial gain, but rather is a way
to demonstrate the physicians carelessness and set an example for the
rest of the medical community.





SEXUAL RELATIONSHIPS WITH A PATIENT



Is always inappropriate and a violation of the ethical standards a
physician is supposed to live by, whether a current or past patient.


Sometimes a relationship is not in violation of ethics if an acceptable
time frame has passed from the last time you saw the patient
professionally (Set by medical boards).
The majority of cases brought upon by patients with the complaint of
an inappropriate sexual encounter do not receive compensatory
damages.

127


ABUSE & NEGLECT

128
 TOPICS:




Child Abuse:
Sexual Abuse
Physical Abuse
Emotional Neglect



Elderly Abuse:
Physical Abuse
Neglect



Domestic Abuse:
Physical Abuse
Emotional Abuse
Sexual Abuse

129
 CHILD ABUSE



The main types of child abuse include: Sexual, Physical, and Emotional

Neglect.



SEXUAL ABUSE:

The majority of the time, the abuser is male.

The majority of the time, the abuser is well---known to the child and
family (< 5% of cases are strangers).
The majority of sexual abuse cases are nine to twelve years of age.

Twenty---five percent of cases are younger than eight years of age.

Twenty---five percent of females and twelve percent of males report
sexual abuse at some point throughout their lives.


Evidence of Abuse:

Trauma to the anal/genital region.

Presence of STD (get a swab).

Precocious sexual behavior with others.

Knowledge about specific sexual acts.

Recurring UTIs.

Presence of anxiety, depression, or other emotional disorders.



Common Characteristics of the Abuser:

They usually have substance abuse problem.

Commonly have problems in their own marriage.

Commonly have dependent personality disorder.

130
 Often have a pedophilia disorder.



Your Role as a Physician:

It is mandatory that you report all cases and suspected cases.

You are allowed to admit a child if you feel they are at risk of further
abuse.
You are not obliged to tell the parents you suspect abuse of any king.





Physical Abuse & Neglect:

Children with some sort of perceived problem are more commonly
physically abused (emotional/mood/etc).
Two---thousand to four---thousand cases of abuse result in death,

annually.

The majority of abused children are younger than fifteen years of age.



Evidence of Abuse:

Child is lacking in personal care (disheveled hair and clothes, rashes
in diaper, etc).
Child appears malnourished and/or is not gaining weight

appropriately.

Cigarette burns.

Fractures at different stages of healing.

Spiral fractures and/or chip fractures.

Immersion burns.

Belt marks.

131
 Signs of physical restraint on wrists and/or ankles.



Characteristics of an Abused Child:

They have a history of low birth---weight and/or prematurity.

They have a history of hyperactivity or ADHD.

They are colicky.



Common Characteristics of the Abuser:

They live in poverty.

They have a history of substance/ETOH abuse.

They have a history of being abused in some capacity themselves.

They have a history of social isolation.






PHYSICAL ABUSE & NEGLECT OF ELDERLY:

Dementia is often a common finding in abused or neglected elderly.

The most common abuser of the elderly is a spouse.

The majority of cases do not get reported.



Signs of Elder Abuse:

Signs of poor personal care.

Signs of malnourishment.

Bruising.

Physical signs of restraint.

Fractures at different stages of healing.

132
 Your Role as a Physician In Elder Abuse:

You are obliged to report all cases of elderly abuse and just as with
child abuse, you can admit a patient if you suspect they are in danger.





DOMESTIC ABUSE:

The majority of domestic abuse cases are not reported.

The majority of the time the male is the abuser.

It is often difficult to convince someone that leaving the partner is
their best choice, mainly because they are:
Dependent on the spouse (financially, emotionally)

They blame themselves

They have low self---esteem

They have nowhere else to go



Characteristics of the Abuser:

Often has a drug and/or ETOH problem.

Is impulsive and doesnt tolerate stress well.

Has a history of displacing feelings.

Abuser usually has low self---esteem.



There is a common cycle of abuse seen, it includes:

There is a buildup of tension in the abuser.

There is abusive behavior (Verbal, Physical).

The abuser is apologetic, demonstrates loving behavior towards the
victim, and is forgiven.

133


Your Role as a Physician in Domestic Abuse:

Provide support.

Discuss options for safety.

You are not required to report domestic abuse to the authorities.






SEXUAL ABUSE (RAPE):

Any type of sexual contact without mutual consent is defined as sexual
abuse. There is no legal requirement for penetration to occur in order
to make a case for rape.


Characteristics of Rapist:

The majority are younger than twenty---five years of age.

They are usually of the same race as the victim.

Drugs and/or ETOH are a part of a third of all rape cases.



Your Role as a Physician in Rape Cases: There are three stages you
have to go through with your patient:


#1 Immediately After The Incident

Get a thorough history

Perform a general physical examination

Get the appropriate laboratory tests

Consider antibiotics and/or abortificants if necessary

Suggest your patient contact the proper authorities

134


#2 Two To Seven Days Later

Discuss emotional and physical state of the patient

Get a pregnancy test

Allow your patient to communicate their feelings

Get a psychiatric consult for your patient

Further discuss legal implications of the case



#3 Six Weeks After Incident

Perform another physical exam

Do a follow---up laboratory panel

Consider sending the patient to counseling if needed



Emotional Consequences:

Often times your patient will develop post---traumatic stress disorder.

Counseling in a group setting is the most effective form of treatment.

135


PEDIATRIC
PSYCHIATRY

136



TOPICS:

Normal Development
Pervasive Developmental Disorders
Depression
Separation Anxiety
Oppositional Defiant Disorder
Conduct Disorder
Attention---Deficit Hyperactivity Disorder

Tourettes Disorder

137
 NORMAL DEVELOPMENT



Normal development is not an exact science, but on average these are
the ages by which children have reached milestones. The main
developmental milestones fall under the following categories:


Social/Emotional

Language/Communication

Cognitive (learning, problem---solving skills, thinking)

Movement/Physical Development



We take a look at these milestones at the following age groups:

2 months

4 months

6 months

9 months

12 months (1 year)

18 months

24 months (2 years)

36 months (3 years)

48 months (4 years)

60 months (5 years)

138
 A DETAILED LOOK AT DEVELOPMENTAL MILESTONES



TWO MONTHS



Social/Emotional:

Smiling begins

Begins purposeful eye contact with parents



Language/Communication:

Coos

Gurgles

Turns head towards sounds



Cognitive:

Facial recognition

Recognizes people



Movement/Physical Development:

Holds head up

Pushes body up when lying on stomach

Arm and leg movement is more coordinated

139
 FOUR MONTHS



Social/Emotional:

Smiles at people

Enjoys playing

Mimics facial movement and expression



Language/Communication:

Babbles

Tries to imitate sounds

Tries to communicate with unique sounds



Cognitive:

Demonstrates emotion

Can reach for objects single---handed

Begins to develop smooth hand---eye co---ordination

Can follow objects visually

Pays greater attention to facial details

Recognizes familiar faces



Movement/Physical Development:

Holds head up unsupported

Rolls from front to back

Begins playing with toys

Brings hand to mouth

Can push onto elbows from lying on stomach

140
 SIX MONTHS



Social/Emotional:

Becomes aware of strangers

Plays with others

Can respond to other peoples emotions

Recognizes self in reflection



Language/Communication:

Responds to noise by making its own noise

Can string vowels together when cooing

Responds to own name

Demonstrates joy and/or displeasure

Begins to use consonants in sounds



Cognitive:

Curiosity about things nearby

Passes object from one hand to the other



Movement/Physical Development:

Can roll over in both directions

Can sit up without support

Can support own weight on legs

Rocking back and forth seen

141
 NINE MONTHS



Social/Emotional:

Fear of strangers

Develops clinginess to familiar adults

Has favorite toys



Language/Communication:

Will understand the word NO

Makes several different sounds

Copies the sounds and gestures of others

Points at things



Cognitive:

Understand when things are hidden

Plays peek a boo

Moves things smoothly from one hand to the other

Has well---developed pincer grasp



Movement/Physical Development:

Stands up while holding onto something

Can get into the sitting position and stay there without support

Can pull to a stand

Crawls quickly

142
 TWELVE MONTHS



Social/Emotional:

Cries when parents leave

Has both favorite objects and/or people in their life

Shows fear in certain situations

Repeats sounds and actions

Helps dress by assisting you

Plays peek a boo and pat---a---cake well



Language/Communication:

Responds to simple spoken requests

Shakes head NO or waves goodbye

Same mama, dada, and uh oh

Changes the tone of verbal expression

Tries to mimic words



Cognitive:

Explores different/new things

Copies gestures

Drinks from cup

Brushes hair

Can poke with index finger

Follows simple directions

Can recognize objects/people in a picture

Recognizes people

143


Movement/Physical Development:

Gets into sitting position without help

Demonstrates cruising (walks while holding onto objects)

May stand alone

Can take a few steps without holding onto objects

144
 EIGHTEEN MONTHS



Social/Emotional:

Hands things to others while playing

Temper tantrums start

Afraid of strangers

Understands concept of playing pretend

Is affectionate towards familiar people

Clings to caregivers in unfamiliar situations

Points things out to other people

Will explore new spaces when parents are close



Language/Communication:

Can say several single words together

Says NO

Shakes head NO

Points to things they want



Cognitive:

Knows what most objects are

Pretends to care for stuffed animals/dolls/etc

Can point out certain bodyparts

Can scribble

Can follow a one---step verbal command

145
 Movement/Physical Development:

Can walk alone

Starts walking up steps

Starts to run

Can help undress self

Can drink from a cup

Can eat with a spoon

146
 TWENTY---FOUR MONTHS (2 YEARS)



Social/Emotional:

Gets excited when other children are around

Shows more independence

Copies others

May start to include other children in their play



Language/Communication:

Can point things out when named

Knows most familiar body parts

Says a 2---4 word sentence

Can follow simple instructions

Can repeat words overheard in conversation

Can point to things in a book



Cognitive:

Begins to sort shapes and colors

Completes a full sentence

Plays make---believe games

Can build a tower of four or more blocks

Starts using a dominant hand

Can follow two---step instructions

147
 Movement/Physical Development:

Can kick a ball

Begins to run

Can climb onto and off of furniture without help

Walks up and down stairs holding on

Throws ball overhand

Can copy straight lines and circles

Can stand on tiptoes

148
 THIRTY---SIX MONTHS (3 YEARS)



Social/Emotional:

Mimics adults

Shows affecting to familiar people

Plays together with others (takes turns playing)

Can demonstrate empathy

Understands concepts such as mine, hers, ours

Demonstrates a variety of emotions

Can separate from parents without becoming overly emotional

Develops routines in daily living

Can dress and undress themselves



Language/Communication:

Can follow two and three---step instructions

Can name most familiar objects

Can say first name, age, and sex

Can get their point across somewhat in conversation

Can speak in two to three---word sentences



Cognitive:

Can do a three/four piece puzzle

Can turn pages one at a time

Can screw and unscrew lids

Can copy a circle with a pencil or crayon

Can build a tower of > six blocks

149


Movement/Physical Development:

Climbs stairs easily one step at a time

Runs easily

Can pedal a tricycle

150
 FORTY---EIGHT MONTHS (4 YEARS)



Social/Emotional:

Creative make---believe play

Can behave co---operatively with others

Prefers group play as opposed to individual play

Likes to try new things



Language/Communication:

Understands the basic rules of grammar

Can sing basic songs from nursery rhymes

Can tell stories

Can tell you their first and last name



Cognitive:

Can name colors and numbers

Can use scissors

Can draw a person with two to three body parts

Can play basic board or card games

Can draw capital letters

Understands time

Can recall parts of a story



Movement/Physical Development:

Can stand up on one foot

Can catch a bouncing ball

151
 SIXTY MONTHS (5 YEARS)



Social/Emotional:

Wants to mimic their friends

Can follow and/or agree with rules

Can show concern for others

Is gender aware

Knows the difference between real and make---believe

Can sign and dance

Demonstrates more independence



Language/Communication:

Speaks in a clear manner

Can tell a story with full sentences

Can use proper verb tense

Knows address



Cognitive:

Can count ten or more objects

Can print some letters and numbers

Can copy geometric shapes

Can draw a body with six body parts



Movement/Physical Development:

Stands on one foot for ten or more seconds

Can hop and skip

152
 Can do a somersault

Can use all utensils to eat

Can use the toilet independently

Can swing and climb



* Developmental milestones courtesy of CDC

153
 PERVASIVE DEVELOPMENTAL DISORDERS



The pervasive developmental disorders are characterized by a childs
failure to develop and/or the early recession of normal social and
language skills for their age. The loss of these skills is lifelong and
subsequently there is a decreased capacity to function normally.


The common pervasive developmental disorders include:

Austism

Aspergers

Rett disorder






AUTISM: Is characterized by problems with communication and
formation of social relationships. Often children engage in repetitive
and/or self---destructive behavior.
2/3 of patients with Autism have below normal intelligence (IQ <70)

Often times, patients have above---average abilities (ie. Excel in playing
the piano)


Characteristics & Prognosis:

Onset is before three years of age

Is much more common in males

If seen in a female, cases is often much more severe

The majority of patients remain impaired into adulthood, with a very
small number able to live independently.

154
 ASPERGERS: Patients have severe problems in forming social
relationships. Patients tend to have repetitive behaviors and
clumsiness. They have little to no delay in language development, and
cognitive development is usually normal.


Characteristics & Prognosis:

Onset is usually between three to five years of age

Is more common in males than females

The prognosis is much better for Aspergers than it is for Autism.






RETTS DISORDER: Is only seen in girls. Patients have a period of
completely normal functioning, followed by a rapid decline in social
skills.


Characteristics & Prognosis:

Onset before four years of age

Patients demonstrate a classic hand---wringing motion

Patients are mentally retarded

This condition progressive with age, with a slight improvement in
social skills as patient ages

155
 CHILDHOOD DEPRESSION



Depression seen in children often times presents itself in a different
manner than depression in adults. While some children may show the
same signs and symptoms, often there are unique findings in different
age groups:


Preschoolers: May demonstrate hyperactivity and/or aggression.
Adolescents: May demonstrate irritability, boredom, or antisocial
behavior.


Management: Examine the childs social situation (ie. Check for family
stressors, check for stressors at school)
Antidepressants are not always used for childhood depression, as
there is an increased risk of suicidal ideation in this population.





SEPARATION ANXIETY



** This is now categorized as a regular anxiety disorder (not isolated to
pediatrics)

When patients are attached to their parents beyond what is considered
normal, separation anxiety is diagnosed. The worry experienced is that
something terrible will happen to the main caregivers (usually the
parents).



156
 Main Signs & Symptoms:

Trouble sleeping at night (ie. Nightmares, insomnia)

157
 Somatic symptoms when separated from caregivers (ie. Nausea,
Vomiting, Diarrhea, etc)


Management: Desensitization therapy, exposing them to the problem
and decreasing their worry.





OPPOSITIONAL DEFIANT DISORDER



The child engages in behavior that is argumentative, angry, and
resentful. This behavior is directed towards people who are in an
authoritative role.


Important: The behavior displayed, while disturbing at times, does not
violate any social norms as does the behavior seen in conduct disorder.


Seen most commonly in children between six and eighteen years of
age.
Oppositional defiant disorder is not a pre---cursor to antisocial

personality disorder.

Before puberty, the condition is more common in boys, while post---

puberty there is an equal ratio of male to female.

158
 CONDUCT DISORDER



Children engage in behaviors that are considered to be dangerous and
against the normal behavior accepted by society. A major factor in
diagnosing is the lack of remorse felt by the child.


The following behavioral traits are commonly seen:

Property destruction

Aggression towards people and animals

Stealing

Lying

Fire---setting

Running away from home

Skipping school



There are different forms based on the age of onset:
Childhood---onset type: Onset is before ten years of age.
Adolescent---onset type: Onset is after ten years of age.
* Overall, onset must be seen before eighteen years of age for the

appropriate diagnosis.

** This IS a pre---cursor to antisocial personality disorder.

159
 ATTENTION---DEFICITY HYPERACTIVITY DISORDER



ADHD is a disorder whereby the child has a group of behavioral
problems that are seen in more than one setting (ie. At school and at
home).


The main characteristics associated with ADHD are:

Hyperactivity

Limited attention span

Impulsiveness

Irritability

Emotional outbursts



In order to make an appropriate diagnosis, keep the following in
mind:
Age of onset before seven years of age.

Symptoms lasting for at least six months.

Is five times more common in boys.



Prognosis: Approximately one in five will maintain the disorder into
adulthood.
ADHD in adulthood leads to an increased risk of mood/personality

disorders.



Management: The 1st line medication of choice is Methylphenidate.

In children, stimulating the CNS increases their ability to concentrate.

160
 TOURETTES DISORDER



Is a disorder characterized by involuntary movements and vocalizations
(tics). Patients typically have several motor tics in addition to at least
one vocal tic. Tourettes commonly begins before the age of eighteen,
with the onset of motor tics beginning as early as eight years of age.
There is no cessation of signs and symptoms of the disorder.


Cause: Dysfunctional regulation of dopamine in the caudate nucleus.



Examples of motor tics:

Blinking

Lip smacking

Grimacing



Examples of vocal tics:

Profanity

Grunting

Barking



Management:

Haloperidol is the mainstay of treatment.

Pimozide is also an effective agent

161


PSYCHIATRIC
PHARMACOLOGY

162

TOPICS:

Anti---Anxiety Medications
Anti---Depressant Medications
Anti---Psychotic Medications
Anti---Mania Medications

163
 ANTI---ANXIETY MEDICATIOS



The two main categories of anti---anxiety medications include:
Benzodiazepines and Non---Benzodiazepines.


Benzodiazepines:

Rapid onset of action.

Different agents have short, intermediate, and long durations of
action.
The benzodiazepines are indicated for other conditions such as sleep

disorders.

Have a high risk of abuse



Non---Benzodiazepines:

Zolpidem is an imidazopyridine that is used to induce rapid sleep, is
not a benzodiazepine.
Buspirone is a good anti---anxiety drug that is less sedating and less

likely to lead to drug dependence/abuse/withdrawal (longer onset of
action than benzodiazepines).

164


Benzodiazepines





























Non---Benzodiazepines

165
 ANTI---DEPRESSANT MEDICATIONS



The main categories of anti---depressant medications include:



Selective Serotonin Receptor Blockers (SSRI)

Heterocyclic Agents

Monoamine Oxidase Inhibitors (MAOIs)



SSRIs:

Main action is the inhibition of serotonin re---uptake.

They have limited effect on other catecholamines like NE, E, DA, and

Ach.

These are much safer and have fewer side---effects as compared to the
other classes of anti---depressants.

166
 Heterocyclic Agents:

Their main action is the inhibition or re---uptake of NE and 5---HT.

Strong anticholinergic action

Highly sedative

Commonly cause weight gain

167
 Monoamine Oxidase Inhibitors:

Irreversible inhibition of MAO, leads to the increase in available NE

and 5---HT in the synapse.

Can lead to hypertensive crisis when combined with foods high in

Tyramine (cheese, wine, beer, some meats/fish).

Combining MAO with SSRI can lead to Serotonin---syndrome

(hyperthermia, convulsions, coma, and even death).

168
 ANTI---PSYCHOTIC MEDICATIONS



The anti---psychotic medications work by decreasing the amount of
dopamine available. The two main categories of medications include
the typicals and atypicals.


Typicals Are stronger and demonstrate greater side---effects than the
atypicals.
Atypicals Are weaker and have fewer side---effects than the typicals.

169
 ANTI---MANIA MEDICATIONS



Anti---mania drugs are used to control the symptoms of mania, which is a
main finding of bipolar disorder. Drugs are used as acute abortificants
and chronic mood---stabilizers.

170
BIOSTATISTICS

171
 TOPICS:


Incidence & Prevalence
Types of Outbreaks
Sensitivity & Specificity
Positive & Negative Predictive Value
Attributable & Relative Risk Odds
Ratio
Standard Deviation
Mean, Median, Mode
Skewed Distribution
Reliability & Validity
Correlation Co---Efficient
Study Types
P---Value Confounding
Variables Bias

172
 INCIDENCE VS. PREVALENCE



Incidence: Is the number of new cases of a disease in a specific unit of
time.
Ex. There were fifty---four cases of influenza diagnosed in the United

States last week.



Prevalence: Is the total number of cases of a disease at a certain point in
time (both new and old).
Ex. There are thirty---two influenza cases at Henry Ford hospital right

now.



Classic USMLE Question: If we treat a disease so people are kept alive
longer but not cured, what can we say about the incidence and the
prevalence of the disease?


Incidence Does not change.

Prevalence Increases.

173
 TYPES OF OUTBREAKS



Epidemic: when new cases of a disease greatly exceed what is expected.

Ex. Asian SARS.



Endemic: new cases are exclusive to a certain place, region, and
population.
Ex. Influenza.



Pandemic: the spread of infectious disease across the large geographic
region.
Ex. Bubonic Plague.








THE USEFUL 2x2 BOX



Drawing a 2x2 box can help simplify the values used for specific
biostatistics questions.
A = True Positive B = False Negative C = False Negative D = True Negative

174
 When we fill in our useful 2x2 box, we have an easy way to remember
which letters represents true positive, true negative, false positive, and
false negative.

175
 SENSITIVITY & SPECIFICITY



Sensitivity: defines a tests ability to detect disease.



Tests with high sensitivity are used as screening tools.

False positives may occur, but a test with high sensitivity wont miss
people with the disease (making it an excellent screening tool).
Ex. Pap Smear, Mammogram, Colonoscopy



Sensitivity = A / A+C

176
 Specificity: is a tests ability to detect healthy individuals.



We use tests with high specificity as confirmatory tests because they
will not identify someone as sick who is actually healthy.
Has a low false positive rate.

An ideal confirmatory test should have a high sensitivity and a high
specificity, otherwise we would identify sick people as healthy.


Specificity = D / D+B

177
 POSITIVE PREDICTIVE VALUE & NEGATIVE PREDICTIVE VALUE



Positive Predictive Value (PPV): measures the probability of having the
disease when there is a positive test for it.


Is measured by taking the true positives and dividing by the total
number of all positives.


PPV = A / A+B

178
 Negative Predictive Value: measures the likelihood that a patient
doesnt have the condition for which they tested negatively.


Is measured by dividing the true negatives by the total negatives

Is inversely related to prevalence (ie. Higher prevalence = lower

NPV)



NPV = D / C+D

179
 TRADE---OFF BETWEEEN SENSITIVITY, SPECIFICITY, PPV, AND NPV




The two points below (A and B), represent the point at which we
consider a disease to be either present (disease) or absent (healthy).
Based on changing the particular cut---off area of these curves, we will
see changes in all four of the values (sensitivity, specificity, PPV, NPV).









































The following two situations are highly tested on the USMLE.

180
 Situation #1: Lets assume the cut---off will be at A.

In the situation above, we moved the cut---off point to A, which will

ensure that all of the diseased people will be caught. With this, we have
a highly sensitive test (ie. Catches all diseased).


With this cut---off, we also notice that many of the healthy individuals
will be considered diseased, meaning we have a lower specificity.
The PPV will go down in this situation because we are including

healthy people into the diseased category, meaning there is a dilution of
the overall positivity of this test.
The NPV will increase because everybody who tests negative for the

disease (ie. Everything to the left of A) will in fact be negative.



Overall: Sensitivity is high, specificity is low, PPV is low, NPV is high.

181
 Situation #2: Lets assume the cut---off will be at B.

When we change the cut---off point to B, we will change the situation

whereby we wont catch all of the diseased, but will detect all of the
healthy individuals. In this situation, we are going to have a test with
decreased sensitivity (ie. We dont catch all of the diseased).


With this cut---off, we also notice that all of the healthy individuals will
be considered healthy, meaning we have a higher specificity.
Our PPV is going to increase because we are not including any

healthy people into our diseased population.

The NPV will decrease because we will include many diseased people
into the healthy population.


Overall: Sensitivity is low, specificity is high, PPV is high, NPV is low

182
 ATTRIBUTABLE RISK



Attributable Risk (AR) is the difference in rate of condition between an
exposed population and an unexposed population.


AR is usually determined through Cohort studies, whereby we follow
a group who is exposed to a risk and a group who is not exposed to the
same risk, then find the difference.


Attributable Risk = [A / (A+B)] [C (C+D)]



Shortcut a person with zero risk factors has an AR of 1---3%, while a
person with 1 risk factor has a risk of disease of 10%.

183
 RELATIVE RISK



Relative Risk (RR) compares the disease risk in people exposed to one
certain risk factor, compared to people not exposed to that same risk
factor.


This is only calculable after a prospective/experimental study (ie.
Can only look forward).
Cannot calculate from a retrospective study (ie. Cannot look back).

A relative risk of 1 says that the relative risk is clinically insignificant.

A RR > 1 says we are that many times more likely to get a disease if
exposed to the certain risk factor.
A RR < 1 says that we are a fraction as likely to get the disease (ie. Is a
sign of protection from the disease).





Example 1: We have run an experimental study that shows a relative
risk of 1.25. Based on this finding, we can say the person is 1.25 times
more likely to get the disease.


Example 2: We have run an experimental study that shows a relative
risk of 0.30. Based on this finding, we can say the person is 3/10 as
likely to get the disease (meaning they are protected from the disease).

184
 ODDS RATIO



The Odds Ratio (OR) looks at the incidence of disease in people exposed
to a risk factor versus the incidence of non---disease in people not
exposed to the risk factor.


OR is calculated from a retrospective study (as opposed to the RR

which is only calculated from the prospective/experimental study).

The goal of OR is to see if there is a difference between the two
populations.
A value of 1 is insignificant (just as with relative risk).

A value > 1 means there is an increased risk, while anything < 1
means there is a protective factor at play.


Odds Ratio = [(A x D) / (B x C)]

185
 STANDARD DEVIATION

68% of the population falls within 1 standard deviation of the highest

point in the curve.
95% of the population falls within 2 standard deviations of the highest
point in the curve.
99.7% of the population falls within 3 standard deviations of the highest
point in the curve.

186
 MEAN, MEDIAN, & MODE



Mean = Average Value

Median = Middle Value

Mode = Most Common Value



Ex. You are given a list of numbers: 2, 2, 3, 4, 4, 5, 6, 6, 7, 7, 7, 7, 9



What is the mean? 5.3 [add the numbers and divide by the number of
values given].
What is the median? 6 [find the number in the middle].

What is the mode? 7 [find the number given most often].



Ex. You are given a list of numbers: 2, 2, 3, 5, 5, 6

What is the median? 4 [take the two middle numbers, add them up and
divide by two].

187
 SKEWED DISTRIBUTIONS



Skewed distributions indicate that the values given are uneven (ie. The
curve isnt bell---shaped). These uneven distributions will render the
standard deviations and means less significant.


Positive Skew: Values are excessively high Mean > Median > Mode

Negative Skew: Values are excessively low Mean < Median < Mode

188
 RELIABILITY & VALIDITY



Reliability measures the reproducibility and consistency of a test.



A test that is reliable will produce the same results no matter how
many different people are performing the test.
Reliability is reduced by random error.



Validity tells us whether a test measures what it says it will.



An example of test validity is the IQ test.

Validity is disturbed with systematic errors.






CORRELATION



Determines the strength of a relationship between two variables.

The distance from zero tells us the strength of correlation.

+1 gives us a perfect correlation (ie. If one value increases so does the
other).
---1 gives us a perfect negative correlation (ie. If one value increases
the other decreases).

189
 CONFIDENCE INTERVAL & P---VALUE



The Confidence Interval will demonstrate how sure we can be that our
means are within a certain range of each other.
The accepted value for confidence interval is ninety---five percent.

Taking date from a populations subset means the means will never
be identical.
We indicate standard deviation in our confidence interval.



Ex. We look at the blood sugar levels of one---hundred people in a
population. It is discovered that the mean blood sugar was 90mg/dL,
with a standard deviation of 5mg/dL.


This is written as follows: 85 < X < 95 = 0.95



It means that 95% of our population has blood sugar levels between

85---95, and we are 95% sure of this.






The p---value is used to determine the significance of the data weve
obtained.
If P < 0.05, this means there is < 5% chance that the data was

obtained by random chance or error.

P < 0.05 is out cutoff point for statistical significance. This does not
however necessarily rule out flaws in the study or imply that there is
clinical significance.

190
 P---VALUE AND THE NULL HYPOTHESIS



A null hypothesis means that something does not work.

Ex. A new drug is being investigated and does not work, so we give it a
null hypothesis.


A null hypothesis that shows statistical evidence suggesting
otherwise is said to be due to random error or chance.
If statistical evidence suggests much differently from the null
hypothesis, we have to reject it.


Ex. A new diabetic drug is given a null hypothesis, but it is shown to
significantly lower blood sugars. We have to reject this null hypothesis
because evidence tells us that it does in fact work. So if the null
hypothesis is wrong, we can say the results are not due to random
chance or error.
If the associated p---value is lower, it gives us more confidence that we

can reject a null hypothesis because we know theres a much smaller
risk of error or random chance.


Type 1 Error: Means youve claimed significance when none exists, or
youve rejected the null hypothesis when it was in fact true (false
positive).
Type 2 Error: Means youve either claimed no significance exists in your

results when there is in fact significance, or youve accepted the null
hypothesis when it was in fact wrong (false negative).

191
 POWER



Power is the odds that someone will reject the null hypothesis when it is
wrong (we want this).


We dont want to accept a null hypothesis when the results are in fact
legit.
The best way to increase your studys Power is by increasing the size
of the sample population.





CONFOUNDING VARIABLES



Confounding variables are unmeasured variables within a sample group
that will affect both the independent and dependent variables.
These are usually extraneous variables that are of no significance
that are inserted into a study and ultimately alter results.
We can control confounding variables by using different forms of
controlled studies.


Independent Variable: Is a manipulated variable.

Dependent Variable: Is an outcome.

192
 STUDY TYPES



Experimental Studies:



Are the Gold---Standard of studies, as it compares two equal groups in
which a single variable is manipulated and then observed/measured.


This study uses double blinding.

This study always uses well---matched controls that are similar.






Prospective Studies:



These are also known as Cohort, Follow---up, Observational, Incidence.



Involves choosing a sample and dividing it into two groups based on
the presence or absence of a risk factor, then following the groups over
time to see what disease(s) develops.
Ex. Follow two groups of smokers and see which develops a higher

incidence of lung cancer later in life.

193
 Retrospective Studies:



Is also known as the Case---Control Study. This type of study chooses a
sample of a population after the fact, based on the presence or absence
of a disease, then information is collected about the risk factors.


We can calculate the odds ratio but not the relative risk or incidence.

Retrospective studies are cheaper, less time---consuming, and better
for rare diseases.
They are not the Gold---Standard.






Prevalence Surveys:



Is also known as Cross---Sectional. It looks at the prevalence of a disease
and the prevalence of risk---factors.


Often used to compare the difference between two different
populations

194
 TYPES OF BIAS



Non---Response Bias:



Occurs when people dont return surveys or answer the phone during a
survey. The greater number of people who dont respond, the greater
the affect it will have on the study.


Lead---Time Bias:



Is based on difference in time.



Ex. If a study demonstrates that a drug prolongs the lives of diabetic
patients, but the study was done on thirty year olds compared to the old
study, which was done on fifty year olds, then the drug doesnt
necessarily prolong lifespan. Because the study was done on younger
people it tended to look that way.


Admission Rate Bias:



Deals with comparing rates of certain things (ex. Mortality) between
two different hospitals. One hospital may show a higher mortality rate
but the study doesnt take into account the fact that one of the hospitals
has tougher admission criteria, while the other is more lenient.

195
 Recall Bias:



Based on improper recalling of the past.






Interviewer Bias:



The person performing the study has decided when and if results were
labeled as significant. Is done to alter results whenever a particular
outcome is desired.





Unacceptability Bias:



Occurs whenever someone fudges their own results by not admitting
things or embellishing their own behaviors in order to please the
interviewer.

196
 CHI---SQUARED, T---TEST, & ANOVA



Chi---Squared Test: Is used to compare proportions and/or percentages.



T---Test: Compares two different means.



ANOVA (analysis of variance): Is used to compare 3 means.

197


EGO DEFENSES

198
 A LIST OF DEFENSE MECHANISMS



The following is a list of the most commonly encountered defense
mechanisms.


Altruism: Assisting others to avoid negative feelings.

Acting Out: Behaving in an outward, attention---seeking manner.
Displacement: Moving one emotion from an unacceptable situation to
one that you find more tolerable.
Denial: Refusing to accept reality because it is unbearable.

Dissociation: Mentally separating part of the personality, or mentally
distancing oneself from others.
Displacement: Moving ones emotions from a personally unacceptable
situation to a more bearable one.
Humor: Using a sense of humor to cover ones discomfort about a

particular situation.

Identification: To pattern ones behavior after someone more
powerful.
Intellectualization: Using ones higher intellect to avoid experiencing

emotions.

Isolation of Affect: Failure to experience any feelings when a stressful
event is experienced.
Projection: Putting ones feelings onto another person.
Rationalization: Changing ones perception in order to make negative
experience seem more positive.

199
 Reaction Formation: Changing ones attitude to the opposite in order
to avoid an unacceptable emotion.
Regression: Reverting to behaviors typical of a younger person.

Splitting: Putting people into different yet absolute categories.
Sublimation: Is the expression of an impulse in a socially accepted
fashion.
Suppression: Moving ones unacceptable emotions out of ones

conscious awareness.

Undoing: Believing one can change an outcome by adopting a more
acceptable behavior.

200