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BRS Behavioral Science Proliferation BRS Pathology. Distribution, posting, or copying of this PDF is strictly prohibited without written permission Ending. BRS Behavioral Science science, psychiatry, epidemiology, and related courses. Distribution, posting, or copying of this PDF is strictly prohibited without. BRS Behavioral soundofheaven.info Stephanie Ha. Chapter 1 The Beginning of Life: Pregnancy Through Preschool Typical Board Question While she previously slept.
Upcoming SlideShare. This female patient is showing evidence of hypocortisolism or Addison disease. Like dopaminergic neurons, noradrenergic neurons synthesize dopamine. Memantine Namenda , a blocker of the N-methyl -d-aspartate NMDA receptor, a type of glutamate receptor, has been approved to treat Alzheimer disease and may prove useful also in the treatment of schizophrenia. Chapter 6 Psychoanalytic Theory and Defense Mechanisms Typical Board Question A year-old woman who was physically abused by her father manages her hostility toward him by baking cookies for him. Attachment 1. Addison disease a.
Middle adolescents 14—17 years often challenge parental authority and have feelings of omnipotence e. Younger adolescents are unlikely to challenge parental rules and authority. Older adolescents 18—20 years have developed self-control and a more real istic picture of their own abilities.
When compared to younger ages, peers and nonfamilial adults become more important to the latency-age child and the family becomes less important. Children 7—11 years of age have the capacity for logical thought, have a conscience, identify wi th the same- sex parent, and show a strong preference for playmates of their own sex. Preschool children usually cannot comprehend the meaning of death and commonly believe that the dead person or pet will come back to life.
Children over the age of 6 ye ars commonly are aware of the finality of death see Chapter 1. Mildly and moderately mentally retarded children are aware that they have a h andicap. They often have low self-esteem and may become socially withdrawn. In part, these problems occur because they have difficulty communicating with and competing with peers.
Peer pressure has a major influence on the behavior of adolescents who tend to do what other adolescents are doing. Depression, the smoking behavior of their parents, and the addictive quality of cigarettes have less of an influence. Most teen agers have been educated with respect to the dangers of smoking. The doctor should remind the parents to pay more attention to the older child.
The child is likely to be frightened by his younger sibling's illness and the attitudes of his parents toward the younger child.
School-age children such as this one may b ecome withdrawn or "act out" by showing bad behavior when fearful or de pressed. While he can be in cluded in the care of his brother, it is not appropriate to insist that he take more responsibility for him. Ignoring his behavior or pu nishing him can increase his fear an d withdrawal.
False reassurance such as telling the child that everything will be fine is not appropriate. As in the Typical Board Question on the previous page , the most appropriate action for the physician to take at this time is to ask to speak to the girl alone. The physician can then ask the girl about her sexual activity and provide contraceptives and counseling if she wishes, without notification or consent from the mother. The mother's wishes in this circumstance are not relevant to th e physician's action; the teenager is the patient.
The formation of a p ersonal identity is usually achieved during the teenage years. The concepts of seriation and conservation and an un derstanding of the concept of "fair play" are gained during the school-age years.
Parallel play is usuall y seen between ages 2 an d 4 years. Latency-age children age 7—11 years have little interest in those of the opposite sex and often criticize or avoid them.
In contrast, younger children do not show strong gender preferences for playmates, and teenagers commonly seek the company of oppo site- sex peers. This child is most likely to be 4 years of age.
Preschool children do not yet understand the concept of conservation i.
Thus, this child believes that a hot dog cut into three pieces has more in it than when it was in only one piece. Children understand this concept better as they approach school age. As in the Typical Board Question and question 12, the physician should talk to this year-old boy alone. In addition to sexual and drug abuse issues, those that involve body image such as obesity ideally should be discussed with a teenager alone, without other family members present. The best thing for the medical student to do at this time is to interact with the child.
Since they do not speak the same language, involving children of this age in an interactive activity such as using the stethoscope or dra wing pictures together is the best choice here.
Neither giving the child a to y nor looking in her e ars is an interactive activity. The student, not the nurse, is responsible for the child in this instance. Sedation is inappropriate at this time; social activity is often effective in de creasing a pa tient's an xiety. Chapter 3 Aging, Death, and Bereavement Typical Board Question An year-old man and his year-old wife are brought to the emergency department after an automobile accident.
The man is dead on arrival. The woman is not seriously injured and is conscious and alert. The couple's son has been called and is on his way to the hospital. The woman asks the physician about her husband's condition. Most correctly, the physician should tell her A. Demographics 1. The fastest growing segment of the population is people over age Differences in life expectancies by gender and race have been decreasing over the past few years.
Gerontology, the study of aging, and geriatrics, the care of aging people, have become important new medical fields. Somatic and neurologic changes 1.
Strength and physical health gradually decline. This decline shows great variability but commonly includes impaired vision, hearing, and immune responses; decreased muscle mass and strength; increased fat deposits; osteoporosis; decreased renal, pulmonary, and gastrointestinal function; reduced bladder c ontrol; and decreased responsiveness to changes in ambient temperature. Changes in the brain occur with aging. These changes include decreased weight, enlarged ventricles and sulci, and decreased cerebral blood flow.
Senile plaques and neurofibrillary tangles are present in the normally aging brain but to a lesser extent than in dementia of the Alzheimer type.
These changes can be associated with psychiatric symptoms such as depression and anxiety see below. Cognitive changes 1. Although learning speed may decrease, in the absence of brain disease, intelligence remains approximately the same throughout life. Some memory problems may occur in normal aging e. However, these problems do not interfe re with the patient's functioning or ability to live independently. Psychological changes 1. In late adulthood there is either a sense of ego integrity i.
Most elderly people achieve ego integrity. Psychopathology and related problems a. Depression is the most common psychiatric disorder in the elderly. Suicide is mo re common in the elderly than in the general population. This misdiagnosed disorder is referred to as pseudodementia because it is associated with memory loss and cognitive problems see Chapter Sleep patterns change, resulting in loss of sleep, poor sleep quality, or both see Chapter Anxiety and fearfulness may be associated with realistic fear-i nducing situations e.
Psychoactive agents may produce different effects in the elderly than in younger patients. For a realistic picture of the functioning level of elderly patients, the physician should ideally evaluate patients in familiar surroundings, such as their own homes.
Life expectancy and longevity 1.
The average lif e expectancy in the United St ates is currently about 76 years. However, this figure varies greatly by gender and race.
The longest-lived group is Asian Americans, particularly the Chinese, and the shortest-lived group is Afri can Americans Table Does Sex Matter? Washington, D. National Academy Press, Factors associated with longevity include a. Family history of longevity b. Continuation of physical and occupational activity c. Advanced education d. Social support systems, including marriage P. The stages usually occur in the following order, but also may be present simultaneously or in another order.
The patient refuses to believe that he or she is dying. The patient may become angry at the physician and hospital staff. You should have checked on me weekly. The patient may try to strike a bargain with God or some higher being. The patient becomes preoccupied with death and may become emotionally detached.
The patient is calm and accepts his or her fate. Th is reaction also occurs with other losses, such as loss of a body part, or, for younger people, with a miscarriage or abortion. A normal grief reaction must be distinguished from an abnormal grief reacti on, which is pathologic Table High Yield Psychiatry, 2nd ed. Characteristics of normal grief bereavement 1. Grief is characterized initially by shock and denial.
In normal grief, the bereaved may experience an illusion see Table that the deceased person is physically present. Normal grief generally subsides after 1— 2 years, although some features may continue longer. Even after they have subsided, symptoms may return on holidays or special occasions the "anniversary reaction". The mortality rate is high for close relatives especially widowed men in the first year of bereavement.
Physician's response to death 1. The major responsibility of the physician is to give support to the dying patient and the patient's family. Generally, physicians make the patie nt completely aware of the diagnosis and prognosis.
However, a physician should follow the patient's lead as to how much he or she wants to know about the condition. With the patient's permission, the physician may tell the family the diagnosis and other details of the illness see Chapter Physicians often feel a sense of failure at not preventing the death of a patient.
They may deal with this sense by becoming emotionally detached from the patient in order to deal with his or her imminent death. Such detachment can preclude helping the patient and family through this important transition. A year-old patient whose wife died 8 months ago reports that he sometime s wakes up an hour earlier than usual and often cries when he thinks about his wife.
He also tells you that on one occasion he briefly followed a woman down the street who resembled his late wife. The patient also relates that he has rejoined his bowling team and enjoys visits with his grandchildren. For this patient, the best recommendation of the physician is A medication for sleep B evaluation for major depression C regular phone calls and visits to "check in" with the doctor D psychotherapy E neuropsychological evaluation for Alzheimer disease View Answer 2.
An year-old woman is being examined by a physician for admission to a nursing home. The woman, who was brought to the doctor by her son, seems anxious and confused. The most effe ctive action for the physician to take at this tim e is to A arrange for immediate admission to a nursing home B conduct a neuropsychological evaluation C suggest immediate hospitalization D ask the son if he has observed changes in the patient's behavior E arrange to examine the woman in her own home View Answer 3.
Each year during the first week in May, a year-old woman develops chest discomfort and a feeling of foreboding. Her husband died 5 years ago during the first week in May. This woman's experience is best described as A an attention-seeking device B pathological grief C an anniversary reaction D malingering E depression View Answer 4. A physician conducts a physical examination on an active, independent year-old woman.
Ninety percent of the patients in a primary care physician's practice are over 65 years of age. When compared to the general population, these elderly patients are more likely to show which of the following psychological characteristics?
The year-old husband of a 70 -year-old woman has just died. If this woma n experiences normal bereavement, which of the following responses would be expected?
A physician has just diagnosed a case of terminal pancreatic cancer in a year -old man. Which of the following state ments regarding the reactions and behavior of the physician is the most true? A She should inform the family, but not the patient, about the serious nature of the illness.
B Her involvement with the patient's family should end when he dies. C She should provide strong sedation for family members when th e patient dies until the initial shock of his death wears off. D She will feel that she has failed when the patient dies. E She will feel closer and closer to the patient as his death approaches.
View Answer 9. The average difference in life expectancy between white women and African American men is approximately A 3 years B 6 years C 10 years D 15 years E 20 years View Answer Six months after the death of a loved one, which of the following is most likely to indicate that a person is experiencing a complicated grief reaction?
An year -old patient tells you that she is concerned beca use she forgets the addresses of people she has just met and takes longer than in the past to do the Sunday crossword puzzle. She plays cards regularly with friends, is well groomed, and shops and cooks for herself. This patient is probably A showing normal aging B showing evidence of Alzheimer disease C experiencing depression D developing an anxiety disorder E unable to live alone View Answer A formerly well-groomed year-old patient appears unshaven a nd disheveled since the death of his wife 8 months ago.
He has lost 15 pounds, has persistent problems sleeping, and has no interest in interacting with friends and family. He also has difficulty relating what he did the previous day or what he ate for lunch today. Physical examination and laboratory tests are unremarkable. For this patient, the best recommendation of the physician is A medication for sleep B evaluation for major depression C regular phone calls and visits to "check in" with the doctor D psychotherapy E neuropsychological evaluation for Alzheimer disease View Answer A year-old woman who is dying of cancer has a year-old son.
The mother does not want the child to know about her illness or prognosis. Most correctly, with respect to the mother's condition the physician should A talk to the mother and encourage her to tell her son B talk to the son alone and tell him about it C follow the mother's wishes and do not tell the son D talk to both the mother and son together E insist that the mother tell her son View Answer P. There is no indication that this elderly woman is impaired mentally or physically.
Therefore, the physician should tell her the truth, i. As with all adult patients, elderly patients should be told the truth. It is not necessary to wait for the son to arrive, and telling her not to worry is patronizi ng. This patient, whose wife died 8 months ago, is showing a normal grief reaction. Although he sometimes wakes up an hour earlier than usual and cries when he thinks about his wife , he is attempting to return to his lifestyle by rejoining his bowling team and visiting with his family.
The illusion of believing he sees and thus follows a woman who resembled his late wife is se en in a normal grief reaction. For a normal grief reaction, recommending regular phone calls and vi sits to "check in" with the doctor i s the appropriate intervention.
Sleep medication, antidepressants, psychotherapy, and a neuropsychological evaluation are not necessary for this patient at this time. The most effective action for the physician to take at this time is to examine the woman in her own home. Anxiety or depression at being in an unfamiliar situation can lead to the anxiety and confusion that this patient shows. Immediate admission to a nursing home or hospital, or interviewing the son are not appropriate until a true picture of the patient's condition has been obtained.
A neuropsychological evaluation also may not be helpful while this patient is showing evidence of severe stress. This woman's experience is best described as an annivers ary reaction. In this reaction, the bereaved person experiences many of the feelings she experienced when her husb and died at significant times in subsequent years. This is considered a normal reaction, not pathological grief, and is not associated with depression.
It is also not a sign of malingeri ng or of seeking attention. During the anger stage of dying, the patient is likely to blame the physician. Of the listed findings, decreased bladder control is t he most likely finding in th e examination of an active, independent year-old woman.
In aging, immune responses and muscle mass decrease and brain ventricles increase in size. Severe memory problems that interfere with normal function indicate the development of a dementia such as Alzheimer disease. Sleep disturbances, such as decreased delta slow wave sleep see Chapter 10 commonly occur in the elderly. Suicide and depression are more common in the elderly than in t he general population.
Anxiety may arise easily due to fears of illness and injury. Intelligence does not decrease with age in normal people. Initial loss of appetite is common in normal bereavement. Feelings of worthlessness or hopelessness, threats of suicide, and an extended period of grief characterize depression rather than normal bereavement. Physicians often feel that they have failed when a pati ent dies.
Rather than becoming closer, this physician may become emotionally detached from the patient in order to deal with his impending death. Heavy sedation is rarely indicated as treatment for the bereaved because it may interfere with the grieving process. Generally, physicians P. The difference in life expectancy between white women 80 years and African American men 65 years is approximately 15 years. The difference in life expectancy by age and sex is currently decreasing.
Six months after the death of a loved one, denying that the death has actually occurred suggests a complicated grief reaction. Normally, denial lasts up to 24 hours. Longing, crying, irritability, and illusions are all part of a normal grief reaction. This year-old woman is probably showing normal aging, since she can function well living alone.
Minor memory loss that does not interfere with normal functioning such as she describes is typically seen in normally aging people. There is no evidence that this patient has Alzheimer dise ase, depression, or an anxiety disorder.
This patient whose wife died 8 months ago shows evidence of an abnormal grief reaction. He is showing signs of depression e. Psychotherapy, while helpful, will be less useful than antidepressant medication for this patient. His sleep will improve as the depression improves. Elderly patients expe riencing depression often present with memory problems that may mimic Alzheimer disease pseudodementia.
The sudden onset of memory problems e. Thus, there is no indication at this time that this patient needs a neuropsychiatric evaluation. It is up to the mother to decide whether, when, and how to tell her son about her illness. However, school-age children are often aware when something serious is going on within their family and can understand the meaning of death.
Theref ore, while it is not appropriate for the physician to insist that the patient tell her son, the physician should talk to the mother and encourage her to talk to her son about her terminal condition. The physician can also counsel the patient on what to say to her child about her imminent death. Chapter 4 Genetics, Anatomy, and Biochemistry of Behavior Typical Board Question When he attempts to divide a line in half, a turn single lines into "Xs", or reproduce a clock face c a year-old man who has had a stroke does the tasks like this see Figure , effectively neglecting the left of the drawings.
The area of the brain most lik ely to be affected in this patient is are the A. There is a genetic component to the etiology of psychiatric disorders such as schizophrenia Chapter 11 and mood disorders Chapter Specific chromosomes have been associated with other disorders with behavioral symptoms Table High Yield Brain and Behavior. Studies for examining the genetics of behavior 1.
Family risk studies compare how frequently a behavioral disorder or trait occurs in the relatives of the affected individual proband with how frequently it occurs in the general population. Twin studies a. Adoption studies using monozygotic twins or dizygotic twins reared in the same or in different homes are used to differentiate the effects of genetic factors from environmental factors in the occurrence of psychiatric and neuropsychiatric disorders.
If there is a genetic component to the etiology, a disorder may be expected to have a higher concordance rate in monozygotic twins than in dizygotic twins i. The CNS contains the brain and spinal cord. The cerebral cortex of the brain can be divided a. Anatomically into at least four sets of lobes: By arrangement of neuron layers or cryo architecture c.
Functionally into motor, sensory, and association areas P. The cerebral hemispheres a. The hemispheres are connected by the corpus callosum, anterior commissure, hippocampal commissure, and habenular commissure. The functions of the hemispheres are lateralized. The right, or nondominant, hemisphere is associated primarily with perception; it also is associated with spatial relations, body image, and musical and artistic ability.
The left, or dominant, hemisphere is associated with language function in about almost all right-handed people and most left-handed people.
Sex differences in cerebral lateralization.
Women may have a larger corpus callosum and anterior commissure and appear to have better interhemispheric communication than men. Men may have better-developed right hemispheres and appear to be better at spatial tasks than women. The PNS contains all sensory, motor, and autonomic fibers outside of the CNS, including the spinal nerves, cranial nerves, and peripheral ganglia. The autonomic nervous system, which consists of sympathetic and parasympathetic divisions, innervates the internal organs.
The autonomic nervous system coordinates emotions with visceral responses such as heart rate, blood pressure, and peptic acid secretion. Visceral responses occurring as a result of psychological stress are involved in the development and exacerbation of some physical illnesses see Chapter Synapses and neurotransmitters 1. Information in the nervous system is transferred across the synaptic cleft i.
When the presynaptic neuron is stimulated, a neurotransmitter is released, travels across the synaptic cleft, and acts on receptors on the postsynaptic neuron. Neurotransmitters are excitatory if they increase the chances that a neuron will fire and inhibitory if they decrease these chances. Presynaptic and postsynaptic receptors are proteins present in the membrane of the neuron that can recognize specific neurotransmitters. The changeability of number or affinity of receptors for specific neurotransmitters neuronal plasticity can regulate the responsiveness of neurons.
Second messengers. When stimulated by neurotransmitters, postsynaptic receptors may alter the metabolism of neurons by the use of second messengers, which include cyclic adenosine monophosphate cAMP , lipids e. Classification of neurotransmitters. Biogenic amines monoamines , amino acids, and peptides are the three major classes of neurotransmitters. Regulation of neurotransmitter activity 1.
The concentration of neurotransmitters in the synaptic cleft is closely related to mood and behavior. A number of mechanisms affect this concentration. After release by the presynaptic neuron, neurotransmitters are removed from the synaptic cleft by mechanisms including: Reuptake by the presynaptic neuron b.
Degradation by enzymes such as monoamine oxidase MAO 3. Availability of specific neurotransmitters is associated with common psychiatric conditions Table Normalization of neurotransmitter availability by pharmacological agents is associated with symptom improvement in some of these disorders see Chapter Overview 1.
The biogenic amines, or monoamines, include catecholamines, indolamines, ethyl amines, and quaternary amines. The monoamine theory of mood disorder hypothesizes that lowered monoamine activity results in depression and elevated levels in mania.
Metabolites of the monoamines are often measured in psychiatric research and diagnosis because they are more easily measured in body fluids than the actual monoamines Table Dopamine 1. Dopamine, a catecholamine, is involved in the pathophysiology of schizophrenia and other psychotic disorders, Parkinson disease, mood disorders, the conditioned fear response see Chapter 7 , and the "rewarding" nature of drugs of abuse see Chapter 9. The amino acid tyrosine is converted to the precursor for dopamine by the enzyme tyrosine hydroxylase.
Receptor subtypes. At least five dopamine receptor subtypes D1—D5 have been identified; the major site of action is D2 for traditional antipsychotic agents and D1 and D4 as well as D2 for the newer "atypical" antipsychotic agents see Chapter Dopaminergic tracts a. The nigrostriatal tract is involved in the regulation of muscle tone and movement. This tract degenerates in Parkinson disease.
Treatment with antipsychotic drugs, which block postsynaptic dopamine receptors receiving input from the nigrostriatal tract, can result in Parkinson-like symptoms. Dopamine acts on the tuberoinfundibular tract to inhibit the secretion of prolactin from the anterior pituitary. Blockade of dopamine receptors by antipsychotic drugs prevents the inhibition of prolactin release and results in elevated prolactin levels.
This elevation in turn results in symptoms such as breast enlargement, galactorrhea, and sexual dysfunction. The mesolimbic-mesocortical tract is associated with psychotic disorders. This tract may have a role in the expression of emotions since it projects into the limbic system and prefrontal cortex. Hyperactivity of the mesolimbic tract is associated with the positive symptoms of schizophrenia; hypoactivity of the mesocortical tract is associated with the negative symptoms of schizophrenia see Chapter Norepinephrine, a catecholamine, plays a role in mood, anxiety, arousal, learning, and memory.
Synthesis a. Like dopaminergic neurons, noradrenergic neurons synthesize dopamine. Most noradrenergic neurons approximately 10, per hemisphere in the brain are located in the locus ceruleus. Serotonin, an indolamine, plays a role in mood, sleep, sexuality, and impulse control.
Elevation of serotonin is associated with improved mood and sleep but decreased sexual function particularly delayed orgasm. Very high levels are associated with psychotic symptoms see Chapter Decreased serotonin is associated with poor impulse control, depression, and poor sleep. The amino acid tryptophan is converted to serotonin also known as 5-hydroxy-tryptamine [5-HT] by the enzyme tryptophan hydroxylase as well as by an amino acid decarboxylase.
Most serotonergic cell bodies in the brain are contained in the dorsal raphe nucleus. Antidepressants and serotonin. Heterocyclic antidepressants HCAs , selective sero-tonin reuptake inhibitors SSRIs , and monoamine oxidase inhibitors MAOIs ulti-mately increase the presence of serotonin and norepinephrine in the synaptic cleft Chapter HCAs block reuptake of serotonin and norepinephrine, and SSRIs such as fluoxetine Prozac selectively block reuptake of serotonin by the presynaptic neuron.
Histamine 1. Histamine, an ethylamine, is affected by psychoactive drugs. Histamine receptor blockade with drugs such as antipsychotics and tricyclic antidepressants is associated with common side effects of these drugs such as sedation and increased appetite leading to weight gain. Acetylcholine Ach a quaternary amine, is the transmitter used by nerve-skeleton-muscle junctions. Degeneration of cholinergic neurons is associated with Alzheimer disease, Down syndrome, and movement and sleep disorders e.
Cholinergic neurons synthesize Ach from acetyl coenzyme A and choline using choline acetyltransferase. The nucleus basalis of Meynert is a brain area involved in production of Ach.
Acetylcholinesterase AchE breaks Ach down into choline and acetate. Blocking the action of AchE with drugs such as donepezil Aricept , rivastigmine Exelon , and galantamine Reminyl may delay the progression of Alzheimer disease but cannot reverse function already lost. Anticholinergic agents are commonly used to treat the Parkinson-like symptoms caused by antipsychotic agents see section IV.
Glutamate 1. Glutamate is an excitatory neurotransmitter that may be toxic to neurons exitotoxicity and thereby contribute to the pathophysiology of disorders such as schizophrenia, Alzheimer disease, and other neurodegenerative illnesses.
Memantine Namenda , a blocker of the N-methyl -d-aspartate NMDA receptor, a type of glutamate receptor, has been approved to treat Alzheimer disease and may prove useful also in the treatment of schizophrenia.
GABA 1. It is synthesized from glutamate by the enzyme glutamic acid decarboxylase, which needs vitamin B6 pyridoxine as a cofactor. GABA is closely involved in the action of antianxiety agents such as benzodiazepines e. The chloride-laden neurons become hyperpolarized and inhibited, decreasing neuronal firing and ultimately decreasing anxiety.
Anticonvulsants also potentiate the activity of GABA. Glycine is an inhibitory neurotransmitter that works on its own and as a regulator of glutamate activity.
Endogenous opioids 1. Enkephalins, endorphins, dynorphins, and endomorphins are opioids produced by the brain itself that decrease pain and anxiety and have a role in addiction and mood.
Placebo effects see Chapter 25 may be mediated by the endogenous opioid system. Prior treatment with an opioid receptor blocker such as naloxone may block placebo effects. Other neuropeptides have been implicated in the following conditions: Schizophrenia cholecystokinin [CCK] and neurotensin 2.
Mood disorders somatostatin, substance P, vasopressin, oxytocin, and corticotropin-releasing factor [CRF] P. Huntington disease somatostatin and substance P 4. Alzheimer disease somatostatin 5. Anxiety disorders substance P and CCK 6. Physical and mental pain and aggression substance P 7. Obesity neuropeptide Y P. A year-old man who has had many negative life experiences becomes upset when he sees photographs of himself taken during these times.
A year-old man comes to the emergency department of a large hospital. He is very anxious and complains of abdominal cramps and diarrhea. The physician observes intense flushing of the man's skin.
In a clinical experiment, a year-old female patient with chronic pain who, in the past, has responded to placebos is given naloxone. Shortly thereafter the patient is given an inert substance that she believes is a painkiller.
After the patient receives the inert substance, her pain is most likely to A increase B decrease C be unchanged D respond to lower doses of opiates than previously E fail to respond to opiates in the future View Answer 4.
Which of the following neuropeptides is most closely implicated in the psychopathology of physical and mental pain? A year-old female patient has had a stroke affecting the left hemisphere of her brain.
Which of the following functions is most likely to be affected by the stroke? Which of the following two structural entities connect the cerebral hemispheres? A Basal ganglia and anterior commissure B Anterior commissure and reticular system C Reticular system and corpus callosum D Hippocampal commissure and corpus callosum E Amygdala and habenular commissure View Answer 7.
A year-old patient shows side effects such as sedation, increased appetite, and weight gain while being treated with antipsychotic medication. The autopsy of a year-old man who was killed when he walked across the street without looking at the traffic light shows degeneration of cholinergic neurons in the hippocampus. In life, this man is most likely to have had which of the following disorders?
A year-old male patient sustains a serious head injury in an automobile accident. He also makes inappropriate suggestive comments to the nurses and masturbates a grea t deal. The area of the brain most likely to be affected in this patient is are the P. A year-old female patient reports that she has difficulty sleeping ever since she sustained a concussion in a subway accident.
The area of the brain most likely to be affected in this patient is are the A right parietal lobe B basal ganglia C hippocampus D reticular system E amygdala F left frontal lobe View Answer A year-old woman was diagnosed with schizophrenia at the age of If this diagnosis was appropriate, the volume of the hippocampus, size of the cerebral ventricles, and glucose utilization in the frontal cortex of this patient are now most likely to be, respectively A increased, increased, increased B decreased, decreased, decreased C decreased, decreased, increased D decreased, increased, decreased E increased, decreased, increased View Answer An year-old female patient has a resting tremor of her left hand, little expression in her face, and problems taking a first step when she has been standing still.
A year-old former bank president cannot tell you the name of the current president and has difficulty identifying the woman sitting next to him his wife. He began having memory problems 3 years ago. The area of the brain most likely to be affected in this p atient is are the A right parietal lobe B basal ganglia C hippocampus D reticular system E amygdala F left frontal lobe View Answer A year-old male patient becomes depressed following a head injury.
A year-old male patient is brought to the emergency room after a fight in which he attacked a man who cut into his line at the supermarket checkout. In the emergency room he remains assaultive and combative.
A year-old woman who is withdrawing from heroin shows intense anxiety, increased pulse, elevated blood pressure, and a hand tremor. The area of the brain most likely to be involved in the improvement in this patient's symptoms is are the A right parietal lobe B basal ganglia C locus ceruleus D raphe nuclei E amygdala F substantia nigra View Answer A very anxious 25 -year-old patient is examined in the emergency room.
There is no evidence of physical illness. A year-old man sustains a head injury in an automobile accident. His father relates that prior to the accident, the pati ent was respectful, modest, controlled, and hard working.
In the hospital, the patient is rude to the nurses and aides, loses his temper with the slightest provocation, and refuses to wear a hospital gown or anything else.
These behavioral changes after the accident indicate that the area of the brain most likely to have been injured in this patient is the A dorsolateral convexity of the frontal lobe B hypothalamus C orbitofrontal cortex D reticular system E amygdala F nucleus basalis of Meynert View Answer Analysis of the blood plasma of a year-old male patient shows increased concentration of homovanillic acid HVA.
This elevation is most likely to be associated with which of the following conditions? Damage to the right parietal lobe can result in impaired visual-spatial processing.
This can lead to problems copying simple drawings and neglect of the left side as seen in this patient. The amygdala is an important brain area for the evaluation of sensory stimuli with emotional significance. Thus, the brain area most likely to be activated by these photos is the amygdala. A hour urine study is most likely to reveal elevated levels of vanillylmandelic acid VMA , a metabolite of norepinephrine.
Anxiety, abdominal cramps and diarrhea, and skin flushing are symptoms of pheochromocytoma, a norepinephrine-secreting adrenal tumor. This picture is not seen with elevated levels of other neurotransmitter metabolites. Since the placebo response is based in part on activation of the endogenous opioid system, it will be blocked by naloxone, and this patient's pain will be unchanged. This experiment will not necessarily affect her response to opioids in the future. Substance P has been implicated in physical and mental e.
Cholecystokinin CCK is implicated in schizophrenia and anxiety disorders; vasopressin, somatostatin, and vasoactive intestinal peptide have been implicated in mood disorders. Somatostatin has been implicated also in Huntington disease and Alzheimer disease. Dominance for language in both right-handed and left-handed people is usually in the left hemisphere of the brain.
Perception, musical ability, artistic ability, and spatial relations are functions primarily of the right side of the brain. The corpus callosum and the hippocampal, habenular, and anterior commissures connect the two hemispheres of the brain. The basal ganglia, reticular system, and amygdala do not have this function. Sedation, increased appetite, and weight gain are side effects of treatment with certain antipsychotic agents. The mechanism most closely associated with these side effects is blockade of histamine receptors since these antipsychotics are not specific for dopamine blockade.
Blockade of dopamine receptors by these antipsychotic medications is associated with side effects such as Parkinsonis m-like symptoms and elevated prolactin levels. Degeneration of cholinergic neurons in the brain is seen in Alzheimer disease, movement disorders, and Down syndrome.
The answer is F. While acetylcholine Ach is the major neurotransmitter implicated in Alzheimer disease, abnormalities in glutamate are seen in both Alzheimer disease and schizophrenia. Blockade of serotonin reuptake by presynaptic neurons is the primary action of the antidepressant fluoxetine. Norepinephrine is metabolized to MHPG. Serotonin is metabolized to 5-HIAA. Sleep-arousal mechanisms are affected by damage to the reticular system. Although neuroimaging cannot be used to diagnose psychiatric disorders, brains of patients with schizophrenia such as this woman are likely to show decreased volume of limbic structures such as the hippocampus; increased size of cerebral ventricles d ue, in part, to brain shrinkage; and decreased glucose utilization in the frontal cortex.
This year-old female patient is showing signs of Parkinson disease e. This disorder is associated with abnormalities of the basal ganglia. This patient is showing evidence of Alzheimer disease. Of the listed brain areas the major one implicated in Alzheimer disease is the hippocampus. Of the listed brain areas, depression is most likely to be associated with damage to the left frontal lobe. Assaultive, impulsive, aggressive behavior like that seen in this year-old male patient is associated with decreased levels of serotonin in the brain.
Levels of 5-HIAA 5-hydroxyindoleacetic acid , the major metabolite of serotonin, have been s hown to be decreased in the body fluids of violent, aggressive, impulsive individuals as well as depressed individuals.
MHPG 3-methoxy hydroxyphenylglycol , a metabolite of norepinephrine, is decreased in severe depression, while homovanillic acid HVA , a metabolite of dopamine, is decreased in Parkinson disease and depression. The effectiveness of clonidine in treating withdrawal symptoms associated with use of opiates and sedatives is believed to be due to its action on alphaadrenergic receptors, e. Thus, the activity of GABA in the brain of this anxious patient is likely to be decreased.
Decreased serotonin and increased norepinephrine are also involved in anxiet y Table Behavioral changes such as decreased impulse control, poor social behavior, and lack of characteristic modesty indicate that the area of the brain most likely to have been injured in this patient is the orbitofrontal cortex. Lesions of this brain area result in disinhibition, inappropriate behavior, and poor judgment. In contrast, lesions of the dorsolateral convexity of the frontal lobe result in decreased executive functioning e.
The hypothalamus is associated with homeostatic mechanisms and the reticular system with consciousness and sleep. Damage to the amygdala results in decreased, not increased, aggression. The nucleus basalis of Meynert is a site of Ach production; its damage could result in deficits in intellectual functioning. Increased body fluid level of homovanillic acid HVA , a major metabolite of dopamine, is seen in schizophrenia.
Decreased HVA is seen in Parkinson disease, depression, and in medicated schizophrenic patients. Increased vanillylmandelic acid VMA , a metabolite of norepinephrine, is seen in pheochromocytoma.
Decreased body fluid level of 5-HIAA, a metabolite of serotonin, is seen in depres sion and in bulimia. The test that the examiner is most likely to be using to evaluate this patient is the A. Luria-Nebraska neuropsychological battery C.
Halstead-Reitan battery D. A va riety of studies ar e used clinically to identify such alterations and abnormalities in patients. Altered levels of biogenic amines and their metabolites occur in some psychiatric conditions see Tables and Plasma levels of some antipsychotic and antidepressant agents are measured to evaluate patient co mpliance or to determine whether therapeutic blood levels of the agent have been reached.
Laboratory tests also are used to monitor patients for complications of pharmacotherapy. Patients taking the mood stabilizer carbamazepine Tegretol or the antipsychotic agent clozapine Clozaril must be observed for blood abnormalities, such as agranulocytosis very low, e. Liver function tests are used in patients being treated with carbamazepine and valproic acid mood stabilizers. Thyroid fu nction and kidney function tests should be used in patients who are being treated with the mood stabilizer lithium.
Patients taking lithium can develop hypothyroidism and, occasionally, hyperthyroidism. Lithium levels also should be monitored regularly because of the drug's narrow therapeutic range see Chapter In a normal patient with a normal hypothalamic-adrenal-pituitary axis, dexamethasone, a synthetic glucocorticoid, suppresses the secretion of cortisol.
In contrast, approximately one half of patients with major depressive disorder have a po sitive DST i. There is some evidence that patients with a positive DST indicating reduced suppression of cortisol will respond well to treatment with antidepressant agents or to electroconvulsive therapy see Chapter The DST has limited clinical usefulness. Positive findings are not specific; non-suppression is seen in conditions other than major depressive disorder.
These disorders include schizophrenia, dementia, Cushing disease, pregnancy, anorexia nervosa or severe weight loss, and endocrine disorders.
Non- suppression is also seen with use, abuse, and withdrawal of alcohol and antianxiety agents. Thyroid function tests ar e used to screen for hypothyroidism and hyperthyroidism, which can mimic depression and anxiety, respectively.
Physical symptoms of hypothyroidism include fatigue, weight gain, edema, hair loss, and cold intolerance. Physical symptoms of hyperthyroidism include rapid heartbeat "palpitations" , flushing, fever, weight loss, and diarrhea. Patients with depression may have other endocrine irregularities, such as positive DST see above , reduced response to a challenge with thyrotropin- releasing hormone, and abnormalities in growth hormone, melatonin, and gonadotropin.
Psychiatric symptoms are associated with endocrine and enzyme disorders, such as Addison disease hypocortisolism , Cushing disease hypercortisolism , and acute intermittent porphyria.
Addison disease a. Physical signs and symptoms include hyperpigmentation of the skin, particularly in skin creases, low blood pressure, pain, fainting, hypoglycemia, diarrhea, and vomiting. Psychiatric symptoms include fatigue, depression, psychosis, and confusion. Cushing disease a. Physical signs and symptoms include round "moon" face, bruising, purple striae on the skin, sweating, facial hair, hypertension, fat on the back of the neck "buffalo hump" , and a positive DST.
Psychiatric symptoms include elevated mood, psychosis, anxiety, and depression. Acute intermittent porphyria a. Physical signs and symptoms include elevated porphobilinogen, severe pain, abdominal cramps, diarrhea and vomiting, seizures, cardiac arrhythmias, flushing, and purple discoloration of urine. Psychiatric symptoms include paranoid delusions and hallucinations, depression, and anxiety. Neuropsychological tests are designed to assess general intelligence, memory, reasoning, orientation, perceptuomotor performance, language function, attention, and concentration in patients with suspected neurologic pr oblems, such as dementia and brain damage Table In such patients, the Folstein Mini-Mental State Examination Table is designed to follow improvement or deterioration and the Glasgow Coma Scale Table is designed to assess level of consciousness by rating patient responsiveness.
Adapted from Fadem B, Simring S. High-Yield Psychiatry, 2nd ed. The reported score is commonly broken down into components e. Drug-assisted interview 1. Administration of a sedative, such as amobarbital sodium "the Am ytal interview" , prior to the clinical interview may be useful in determining whether organic pathology is responsible for symptomatology in patients who exhibit certain psychiatric disorders or malingering see Chapter This will allow patients to express themselves coherently during the interview.
Sodium lactate administration. Intravenous IV administration of sodium lactate can provoke a pa nic attack see Chapter 13 in susceptible patients and can thus help to identify individuals with panic disorder.
Inhalation of carbon dioxide can produce the same effect. Galvanic skin response a component of the "lie detector" test 1. The electric resistance of skin galvanic skin response varies with the patient's psychological state. Higher sweat gland activity, seen with sympathetic nervous system arousal e. However, innocent but anxious people may also have positive tests false positives. A year-old male patient is admitted to the hospital complaining of intense abdominal pain, nausea, and diarrhea.
He states that over the past few days he has also been very "nervous" and depressed. When his urine is collected it appears purple in color. A year-old female patient comes to the physician complaining of extreme fatigue and depression. Physical examination reveals a da rkening of her skin, particularly in the creases of her hands and on the buccal mucosa. The most likely cause of this picture is A hypocortisolism B hypercortisolism C pheochromocytoma D hypothyroidism E hyperthyroidism View Answer 3.
A physician administers sodium lactate in travenously to a 28 -year-old wo man. Using this technique, th e ph ysician is trying to provoke, and thus confirm, the patient's diagnosis of A conversion disorder B amnestic disorder C malingering D panic disorder E major depression View Answer 4. A year-old female patient shows a sudden loss of sensory function below the waist that cannot be medically explained. To differentiate delirium from dementia in a year-old male patient, th e mo st ap propriate diagnostic technique is P.
A year-old wo man reports th at she has little appetite, sleeps poorly, and has lo st interest in her no rmal activities. Wh ich of the following is the most likely laboratory finding in this woman? A year-old man reports that over the past few months he has begun to experience intense anxiety and has lost 15 pounds.
The patient also complains of "flushing, palpitations" and diarrhea. Which of the following is the most likely laboratory finding in this man? A college-educated year-old female patient has scored 15 on the Folstein Mini-Mental State Examination. Four weeks after he begins to take a new medication, a 2 8-year-old male psychiatric patient develops a fe ver and a sore throat.
He reports feeling tired, and blood studies reveal a white blood cell WBC count of less than 2, This patient is most likely to be taking which of the following agents? The Bender Visual Motor Gestalt Test is used to evaluate visual and motor ability by reproduction of designs. The Luria-Nebraska neuropsychological battery is used to determine cerebral dominance and to identify specific types of brain dysfunction, while the Halstead-Reitan battery is used to detect and localize brain lesions and determine their effects.
The dexamethasone suppression test is used to predict which depressed patients will respo nd well to treatment with antidepressant agents or electroconvulsive therapy. The electroencephalogram EEG , which measures electrical activity in the cortex, is useful in dia gnosing epilepsy and in differentiating delirium from dementia. This patient with abdominal pain, nausea, diarrhea, and purplish urine is most likely to have porphyria, which is associated with high levels of porphobilinogen in ur ine.
Porphyria is a metabolic disorder in which toxic porphyrins accumulate in tissue and body fluids. This female patient is showing evidence of hypocortisolism or Addison disease. This condition is characterized by darkening of the skin, particularly in places not exposed to the sun such as skin creases and inside the mouth.
This darkening is not seen in hypercortisolism, pheochromocytoma, or hyper-or hypothyroidsm. Hypercortisolism, which also may lead to depression and anxiety, is characterized by weight gain, "moon" facies, and skin striae. Depression, dry hair, and weight gain characterize hypothyroidism, while anxiety, fever, weight loss, and elevated heart rate characterize hyperthyroidism. Patients with pheochromocytoma show intense anxiety and elevated VMA in body fluids see Chapter 4.
Intravenous administration of sodium lactate can help identify individuals with panic disorder since it can provoke a panic attack in such patients. Positron emission tomography PET localizes physiologically active brain areas by measuring glucose metabolism. Thus, this test can be used to determine which brain ar ea is being used during a sp ecific task e. The auditory evoked EEG can be used to assess whether this child can hear.
Evoked EEGs measure electrical activity in the cortex in response to sensory stimulation. The amobarbital sodium Amytal interview is used to determine whether psychological factors are responsible for symptoms in this patient who shows a n on-medically explained loss of sensory function conversion disorder—see Chapter Computed tomography CT identifies organically based brain changes, such as enlarged ventricles.
Thus, although not diagnostic, this test can be used to identify anatomical changes in the brain, such as enlarged ventricles in a patient with suspected dementia of the Alzheimer type. Poor appetite, poor sleep, and lack of interest in normal activities characterize patients who have major depression see Chap ter In this depressed woman, the dexamethasone suppression test is likely to be positive.
A positive result is seen when the synthetic glucocorticoid dexamethasone fails to suppress the secretion of cortisol as it would in a normal patient. Also, in depression there may be abnormal growth hormone regulation and melatonin levels, and decreased 5-HIAA.
Offering current coverage of behavioral science, psychiatry, epidemiology, and related courses, this review book prepares you to rapidly recall key information on the mind-body relationship, and apply that knowledge on the day of the exam. Chapters cover the full range of behavioral science, from growth and development through assessment, specific disorders, therapies, legal and ethical issues, and much more.
Each chapter begins with a "Typical Board Question," which provides an example of how the subject is tested and familiarizes you with what you re likely to see on the USMLE. This edition conforms with the most recent psychiatric classification system, the DSM More than USMLE-style, clinical vignette questions many new to this edition , along with detailed answers, are found in Review Tests at the end of each chapter and a Comprehensive Examination at the end of the book.
Written in outline format for efficient review and study. An interactive online question bank makes it easy for you to create personalized practice tests to gauge your understanding. SlideShare Explore Search You. Submit Search. Successfully reported this slideshow. We use your LinkedIn profile and activity data to personalize ads and to show you more relevant ads. You can change your ad preferences anytime. Upcoming SlideShare. Like this presentation?
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