Professional Documents
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Behavior Science
Behavior Science
S EVENTH EDITION
Beh avioral Scien ce
S EVENTH EDITION
Seven th Edition
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9 8 7 6 5 4 3 2 1
Th is work is p rovided “as is,” an d th e p u blish er disclaim s an y an d all warran ties, exp ress or im p lied,
in clu din g an y warran ties as to accu racy, com p reh en siven ess, or cu rren cy o th e con ten t o th is work.
Th is work is n o su bstitu te or in divid u al p atien t assessm en t based u p on h ealth care p ro ession als’
exam in ation o each p atien t an d con sid eration o , am on g oth er th in gs, age, weigh t, gen der, cu rren t or
p rior m ed ical con d ition s, m edication h istory, lab oratory data an d oth er actors u n iqu e to th e p atien t. Th e
p u blish er does n ot p rovide m ed ical ad vice or gu id an ce an d th is work is m erely a re eren ce tool. Health care
p ro ession als, an d n ot th e p u b lish er, are solely resp on sib le or th e u se o th is work in clu d in g all m ed ical
ju dgm en ts an d or an y resu ltin g d iagn osis an d treatm en ts.
Given con tin u ou s, rap id ad van ces in m ed ical scien ce an d h ealth in orm ation , in dep en d en t p ro ession al
veri ication o m edical diagn oses, in dication s, ap p rop riate p h arm aceutical selection s an d dosages, an d
treatm en t op tion s sh ou ld b e m ade an d h ealth care p ro ession als sh ou ld con su lt a variety o sou rces. Wh en
p rescrib in g m edication , h ealth care p ro ession als are advised to con su lt th e p rod u ct in orm ation sh eet (th e
m an u actu rer’s p ackage in sert) accom p an yin g each dru g to veri y, am on g oth er th in gs, con dition s o u se,
warn in gs an d sid e e ects an d id en ti y an y ch an ges in dosage sch ed u le or con train dication s, p articu larly
i th e m ed ication to b e adm in istered is n ew, in requ en tly u sed or h as a n arrow th erap eu tic ran ge. To th e
m axim u m exten t p erm itted u n der ap p licable law, n o resp on sibility is assu m ed by th e p u blish er or an y
in ju ry an d/ or d am age to p erson s or p rop erty, as a m atter o p rod u cts liab ility, n egligen ce law or oth erwise,
or rom an y re eren ce to or u se by an y p erson o th is work.
LWW.com
I lovingly dedicate the seventh edition o this book to Daniel, J onathan,
Terri, Sarah, and J oseph Fadem and Tom, Fif , and Hasu Chenal
Reviewers
vii
Pre ace
ix
Ackn owledgm en ts
Th e au th or wish es to th an k Crystal Taylor o Wolters Klu wer, Lip p in cott William s & Wilkin s, or
h er en cou ragem en t an d p ractical assistan ce with th e m an u scrip t. As always, th e au th or th an ks
with great a ection an d resp ect th e carin g, in volved m edical stu den ts with wh om sh e h as h ad
th e h on or o workin g over th e years. Sp ecial th an ks to Meredith Bran don , M.D., or h er in p u t
in to Ch ap ter 16.
xi
Con ten ts
xiii
xiv Contents
7. LEARNING THEORY 65
I. Overview 65
II. Habitu ation an d Sen sitization 65
III. Classical Con dition in g 66
IV. Op eran t Con dition in g 66
Review Test 69
9. SUBSTANCE-RELATED DISORDERS 83
I. Su bstan ce-related Disorders: Def n ition s, Ep idem iology, an d
Dem ograp h ics 83
II. Stim u lan ts 84
III. Sedatives 85
IV. Op ioids 87
V. Hallu cin ogen s an d Related Agen ts 88
VI. Clin ical Featu res o Su bstan ce-related Disorders 89
VII. Man agem en t 90
Review Test 91
B. Premature birth
1. Premature births an d very premature births are de in ed as th ose ollowin g a gestation o less
th an 37 an d 32 completed weeks , resp ectively.
2. Prem atu re b irth p u ts a ch ild at greater risk or dyin g in th e irst year o li e an d or em o-
tion al, beh avioral, an d learn in g p roblem s as well as physical an d intellectual disabilities .
3. Prem atu re b irth s, wh ich are associated with low in com e, m atern al illn ess or m aln u trition ,
an d you n g m atern al age, occu r in alm ost twice as m an y n on -Hisp an ic A rican -Am erican
in an ts th an n on -Hisp an ic Wh ite in an ts.
C. Infant mortality
1. Low socioeconomic status , wh ich is related in p art to eth n icity, is associated with p rem a-
tu rity an d h igh in an t m ortality (Table 1.1).
2. In p art, becau se th e Un ited States d oes n ot h ave a system o h ealth care or all citizen s
p aid or by th e govern m en t th rou gh taxes, p rem atu rity an d in an t m ortality rates in th e
Un ited States are h igh as com p ared to th e rates in oth er develop ed cou n tries (Figu re 1.1).
1
2 BRS Behavioral Science
3. Th e Apgar score (named for Dr. Virginia Apgar but useful as a mnemonic): A—appearance
(color), P—pulse (heartbeat), G—grimace (reflex irritability), A—activity (muscle tone),
R—respiration (breathing regularity), qu an ti ies p h ysical u n ction in g in p rem atu re an d
u ll-term n ewborn s (Table 1.2) an d can be u sed to p redict th e likelih ood o im m ediate
su rvival.
Th e in an t is evalu ated 1 m in u te an d 5 (or 10) m in u tes a ter birth . Each o th e ive m easu res
can h ave a score o 0, 1, or 2 (h igh est score = 10). Score >7 = n o im m in en t su rvival th reat; score
<4 = im m in en t su rvival th reat.
Ja pa n 2.3
S we de n 2.5
S pa in 3.2
Ge rma ny 3.4
Ita ly 3.4
Ca na da (2009) 4.9
Unite d S ta te s 6.1
0 1 2 3 4 5 6
Ra te pe r 1,000 live births
FIGURE 1.1. Infant mortality rates: Selected Organisation for Economic Co-operation and Development countries, 2010
(Selected countries). (From: International comparisons of infant mortality and related factors: United States and Europe.
Natl Vital Stat Rep. 63 (5), 2014 Figure 1.)
Chapter 1 The Beginning of Life: Pregnancy Through Preschool 3
Score
Measure 0 1 2
Postpartum blues 33%–50% Within a few days Up to 2 wk after Exaggerated emotionality and
(“baby blues”) after delivery delivery tearfulness
Interacting well with friends and
family
Good grooming
Major depressive 5%–10% Within 4 wk after Up to 1 y without Feelings of hopelessness and
disorder delivery treatment; 3–6 wk helplessness
with treatment Lack of pleasure or interest in
usual activities
Poor self-care
May include psychotic
symptoms (“major
depressive disorder with
psychotic features”), e.g.,
hallucinations and delusions
(see Table 11.1)
Mother may harm infant
Brief psychotic 0.1%–0.2% Within 4 wk after Up to 1 mo Psychotic symptoms not better
disorder delivery accounted for by major
(postpartum depressive disorder with
onset) psychotic features
Mother may harm infant
4 BRS Behavioral Science
3. Wom en wh o are ed u cated an d p rep ared or ch ildbirth h ave sh orter labors, ewer m edical
com p lication s, less n eed or m ed ication , an d closer in itial in teraction s with th eir in an ts.
C. Studies of attachment
1. Harry Harlow d em on strated th at in an t m on keys reared in relative isolation by surrogate
artificial mothers d o n ot develop typ ical m atin g, m atern al, an d social beh avior as adu lts.
a. Males m ay b e m ore a ected th an em ales by su ch isolation .
b. Th e length of time of isolation is im p ortan t. You n g m on keys isolated or less th an
6 m on th s can b e reh ab ilitated by p layin g with typ ical you n g m on keys.
2. René Spitz docu m en ted th at ch ild ren with ou t p rop er m oth erin g (e.g., th ose in orp h an -
ages) sh ow severe developmental retardation, p oor h ealth , an d h igh er death rates (“hospi-
talism”) in sp ite o ad equ ate p h ysical care.
3. Partly b ecau se o su ch in d in gs, th e foster care system was establish ed or you n g ch ildren
in th e Un ited States wh o d o n ot h ave ad equ ate h om e situ ation s. Foster am ilies are th ose
th at h ave b een ap p roved an d u n d ed by th e state o residen ce to take care o a ch ild in
th eir h om es.
t a b l e 1.4 Reflexes Present at Birth and the Age at which They Disappear
Palmar grasp The child’s fingers grasp objects placed in the palm 2 mo
Rooting and sucking The child’s head turns in the direction of a stroke on the cheek 3 mo
reflexes when seeking a nipple to suck
Startle (Moro) reflex When the child is startled, the arms and legs extend 4 mo
Babinski reflex Dorsiflexion of the largest toe when the plantar surface of the 12 mo
child’s foot is stroked
Tracking reflex The child visually follows a human face Continues
Chapter 1 The Beginning of Life: Pregnancy Through Preschool 5
Skill Area
Age (in Months) Motor Social Verbal and Cognitive
1–3 Lifts head when lying prone Smiles in response to a Coos or gurgles in response to
human face (the “social human attention
smile”)
4–6 Turns over (5 mo) Forms an attachment to Babbles (repeats single
Sits unassisted (6 mo) primary caregiver sounds over and over)
Reaches for objects Recognizes familiar people
Grasps with entire hand (“raking
grasp”)
7–11 Crawls on hands and knees Shows stranger anxiety Imitates sounds
Pulls self up to stand Plays social games such Uses gestures
Transfers toys from hand to hand as peek-a-boo, waves Responds to own name
(10 mo) “bye-bye” Responds to simple
Picks up toys and food using instructions
“pincer” (thumb and
forefinger) grasp (10 mo)
12–15 Walks unassisted Shows separation anxiety Says first words
Shows object permanence
(2) In an ts exp osed to m an y caregivers are less likely to sh ow stran ger an xiety th an
th ose exp osed to ew caregivers.
c. At ab ou t 1 year, th e ch ild can m ain tain th e m en tal im age o an object or o th e m oth er
with ou t seein g it or h er (“object permanence ”).
E. Theories of development
1. Chess an d Thomas sh owed th at th ere are endogenous differences in th e temperaments o
in an ts th at rem ain qu ite stable or th e irst 25 years o li e. Th ese di eren ces in clu de such
ch aracteristics as reactivity to stim u li, resp on siven ess to p eop le, an d atten tion sp an .
a. Easy children are adap table to ch an ge, sh ow regu lar eatin g an d sleep in g p attern s, an d
h ave a p ositive m ood .
b. Difficult children sh ow traits op p osite to th ose o easy ch ild ren .
c. Slow-to-warm-up children sh ow traits o di icu lt ch ildren at irst bu t th en im p rove an d
adap t with in creased con tact with oth ers.
2. Sigmund Freud d escrib ed d evelop m en t in term s o th e p arts o th e b od y rom wh ich th e
m ost p leasu re is d erived at each stage o develop m en t (e.g., th e “oral stage” occu rs du rin g
th e irst year o li e).
3. Erik Erikson describ ed d evelop m en t in term s o critical p eriods or th e ach ievem en t o
social goals; i a sp eci ic goal is n ot ach ieved at a sp eci ic age, th e in dividu al will h ave di -
icu lty ach ievin g th e goal in th e u tu re. For exam p le, in Erikson’s stage o basic trust versus
mistrust, ch ild ren m u st learn to tru st oth ers du rin g th e irst year o li e or th ey will h ave
trou ble orm in g close relation sh ip s as adu lts.
4. J ean Piaget described developm en t in term s o learn in g capabilities o the child at each age.
5. Margaret Mahler describ ed early d evelop m en t as a sequ en tial p rocess o sep aration o th e
ch ild rom th e m oth er or p rim ary caregiver.
t a b l e 1.6 Motor, Social, Verbal, and Cognitive Development of the Toddler and
Preschool Child
Skill Area
Age (Years) Motor Social Verbal and Cognitive
1.5 Throws a ball Moves away from and then Uses about 10 individual
Stacks three blocks returns to the mother for words
Climbs stairs one foot at a time reassurance (rapprochement) Says own name
Scribbles on paper
2 Kicks a ball Shows negativity (e.g., the favorite Uses about 250 words
Balances on one foot for 1 s word is “no”) Speaks in two-word
Stacks six blocks Plays alongside but not with sentences and uses
Feeds self with spoon another child (“parallel play”: pronouns (e.g., “me do”)
2–4 y of age) Names body parts and objects
3 Rides a tricycle Has a sense of self as male or Uses about 900 words in
Undresses and partially dresses female (gender identity) speech
without help Usually achieves bowel and Understands about 3,500
Climbs stairs using alternate bladder control (problems words
feet such as encopresis [“soiling”] Identifies some colors
Stacks nine blocks and enuresis [“bed wetting”] Speaks in complete
Copies a circle cannot be diagnosed until 4 sentences (e.g., “I can do
and 5 y of age, respectively) it myself”)
Comfortably spends part of the Strangers can now
day away from mother understand her
4 Catches a ball with arms Begins to play cooperatively with Shows good verbal self-
Dresses independently, using other children expression (e.g., can tell
buttons and zippers Engages in role playing (e.g., “I’ll detailed stories)
Grooms self (e.g., brushes teeth) be the mommy, you be the Comprehends and uses
Hops on one foot daddy”) prepositions (e.g., under,
Draws a person May have imaginary companions above)
Copies a cross Curious about sex differences
(e.g., plays “doctor” with other
children)
Has nightmares and transient
phobias (e.g., of “monsters”)
5 Catches a ball with two hands Has romantic feelings about Shows further improvement
Draws a person in detail (e.g., the opposite sex parent (the in verbal and cognitive
with arms, hair, eyes) “oedipal phase”) at 4–5 y of skills
Skips using alternate feet age
Copies a square Overconcerned about physical
injury at 4–5 y of age
6 Ties shoelaces Begins to develop an internalized Begins to think logically (see
Rides a two-wheeled bicycle moral sense of right and wrong Chapter 2)
Prints letters Begins to understand the finality Begins to read
Copies a triangle of death
3. Th ere is n o com p ellin g eviden ce th at daily sep aration rom workin g p aren ts in a good day
care settin g h as sh ort- or lon g-term n egative con sequ en ces or ch ildren . However, wh en
com p ared to ch ildren wh o stay at h om e with th eir m oth ers, th ose wh o h ave been in day
care sh ow m ore aggressiveness .
2. A ch ild wh o can n ot do th is a ter age 3 is exp erien cin g separation anxiety disorder (see
Ch ap ter 15).
3. Presch ool ch ild ren m ay p erceive death as a punishment or bad beh avior. Th ey believe th at
death is tem p orary an d typ ically exp ect th at a d ead relative (or p et) will com e b ack to li e.
B. Characteristics
1. Th e ch ild’s vocabulary increases rap id ly. Th e 3-year-old ch ild can typ ically say abou t 900
words an d sp eaks in com p lete sen ten ces.
2. Toilet training typ ically occu rs at age 3 years. Delayed toilet train in g is m ost o ten related
to p h ysiological im m atu rity du e to gen etic actors, or exam p le, th e ath er was also a “bed
wetter” as a ch ild.
3. Th e birth o a siblin g or oth er life stress , su ch as m ovin g or divorce, m ay resu lt in a ch ild’s
u se o regression, a d e en se m ech an ism (see Ch ap ter 6) in wh ich th e ch ild tem p orarily
beh aves in a “b aby-like” way (e.g., alth ou gh h e is toilet train ed, h e starts wettin g th e bed
again ). Regression o ten occu rs in typ ical ch ild ren as a reaction to li e stress.
4. Ch ild ren can d istin gu ish an tasy rom reality (e.g., th ey kn ow th at im agin ary rien d s are
n ot “real” p eop le), alth ou gh th e lin e between th em m ay still n ot be sh arp ly drawn .
5. Presch ool ch ild ren are typ ically active an d rarely sit still or lon g.
6. Oth er asp ects o m otor, social, verbal, an d cogn itive develop m en t o th e p resch ool ch ild
can be ou n d in Tab le 1.6.
1. Paren ts o a 13-m on th -old ch ild tell th e 4. An Am erican cou p le wou ld like to adop t
doctor th at th e ch ild sh ows n o in terest in a 10-m on th -old Rom an ian ch ild . However,
toilet train in g. Th ey also relate th at th e ch ild th ey are con cern ed becau se th e ch ild
sp eaks abou t 10 word s an d h as ju st started h as been in an orp h an age sin ce h e was
to walk u n assisted. Th e doctor sh ou ld sep arated rom h is birth m oth er 5 m on th s
(A) tell th e p aren ts th at th e ch ild’s h earin g ago. Th e orp h an age is clean an d well kep t
sh ou ld be ch ecked as soon as p ossible bu t h as a h igh sta tu rn over ratio. Wh ich o
(B) con tact ch ild p rotective services th e ollowin g ch aracteristics is th e cou p le
(C) reassu re th e p aren ts th at th e ch ild’s m ost likely to see in th e ch ild at th is tim e?
beh avior is typ ical or h er age (A) Lou d cryin g an d p rotests at th e loss o
(D) re er th e am ily to a p ediatric h is m oth er
gastroen terologist (B) In creased resp on siven ess to adu lts
(E) evalu ate th e ch ild or d elayed m otor (C) Typ ical develop m en t o m otor skills
develop m en t (D) Reactive attach m en t disorder
(E) Typ ical develop m en t o social skills
2. In a m ajor city h osp ital, th e h earin g o
all n ewborn s is evalu ated sh ortly a ter b irth . 5. Wh en a p h ysician con du cts a well-ch ild
Th e m ajor objective o th is h earin g loss ch eck u p on a typ ical 2-year-old girl, th e
screen in g is to ch ild is m ost likely to sh ow wh ich o th e
(A) determ in e th e n ecessity o u sin g coch lear ollowin g skills or ch aracteristics?
im p lan ts be ore th e age o 6 m on th s (A) Sp eaks in two-word sen ten ces
(B) determ in e th e n ecessity o sp eech (B) Is toilet train ed
th erapy b e ore th e age o 1 year (C) Can com ortably sp en d m ost o th e day
(C) diagn ose an d treat h earin g loss early in away rom h er m oth er
order to p reven t lan gu age develop m en t (D) Can ride a tricycle
delay (E) En gages in coop erative p lay
(D) diagnose an d treat hearing loss early in
order to preven t m otor developm en t delay 6. Wh en a p h ysician con du cts a well-ch ild
(E) in crease th e cost-e ectiven ess o ch eck u p on a 3-year-old boy, h e f n ds th at
treatm en t or h earin g loss th e ch ild can ride a tricycle, copy a circle,
en gage in p arallel p lay with oth er ch ildren ,
3. Th e con cern ed p aren ts o a 5-year-old n am e som e o h is body p arts (e.g., n ose,
ch ild rep ort th at th e ch ild is still wettin g eyes) bu t n ot oth ers (e.g., h an d, f n ger),
th e bed . Th e ch ild is oth erwise d evelop in g an d h as abou t a 50-word vocabu lary. With
ap p rop riately or h is age an d p h ysical resp ect to m otor, social, an d cogn itive/
exam in ation is u n rem arkab le. Th e ch ild’s verbal skills, resp ectively, th e best
ath er was also a bed wetter u n til age 8 years. descrip tion o th is ch ild is
Th e m ost com m on cau se o en u resis in a (A) typ ical, typ ical, n eeds evalu ation
ch ild o th is age is (B) typ ical, typ ical, typ ical
(A) em otion al stress (C) n eeds evalu ation , typ ical, n eeds
(B) p h ysiological im m atu rity evalu ation
(C) sexu al ab u se (D) typ ical, n eeds evalu ation , n eeds
(D) u rin ary tract in ection evalu ation
(E) m ajor dep ression (E) typ ical, n eeds evalu ation , typ ical
8
Chapter 1 The Beginning of Life: Pregnancy Through Preschool 9
7. A m oth er brin gs h er 4-m on th -old ch ild to 11. A well-train ed, h igh ly qu alif ed
th e p ediatrician or a well-baby exam in ation . obstetrician h as a bu sy p ractice. Wh ich
Wh ich o th e ollowin g develop m en tal o the ollowin g is m ost likely to be tru e
sign p osts can th e doctor exp ect to be p resen t abou t p ostp artu m reaction s in th is doctor’s
in th is in an t i th e ch ild is develop in g p atien ts?
typically? (A) Postp artu m blu es will occu r in abou t
(A) Stran ger an xiety 10% o th e p atien ts.
(B) Social sm ile (B) Major dep ression will occu r in abou t
(C) Rap p roch em en t 25% o th e p atien ts.
(D) Core gen der iden tity (C) Brie p sych otic disorder will occu r in
(E) Ph obias abou t 8% o th e p atien ts.
(D) Brie p sych otic disorder will u su ally last
8. Th e overall in an t m ortality rate in th e abou t 1 year.
Un ited States in 2010 was ap p roxim ately (E) Postp artu m blu es will u su ally last u p to
(A) 1 p er 1,000 live b irth s 2 weeks.
(B) 3 p er 1,000 live b irth s
(C) 6 p er 1,000 live b irth s 12. A wom an in th e 7th m on th o p regn an cy
(D) 11 p er 1,000 live birth s with h er th ird ch ild tells h er p h ysician sh e is
(E) 40 p er 1,000 live birth s worried th at sh e will exp erien ce d ep ression
a ter th e ch ild is born . Th e m ost im p ortan t
9. Th e m ost im p ortan t p sych ological task or th in g or th e doctor to say at th is tim e is
a ch ild b etween birth an d 15 m on th s is th e (A) “Do n ot worry, th ere are m an y e ective
develop m en t o m ed ication s or d ep ression .”
(A) th e ability to th in k logically (B) “Wom en o ten becom e m ore an xiou s
(B) sp eech toward th e en d o th eir p regn an cy.”
(C) stran ger an xiety (C) “Did you exp erien ce an y em otion al
(D) a con scien ce di icu lties a ter th e birth o you r oth er
(E) an in tim ate attach m en t to th e m oth er or ch ildren ?”
p rim ary caregiver (D) “Do you wan t to start takin g
an tid ep ressan t m ed ication n ow?”
10. Th e h u sban d o a 28-year-old wom an , (E) “Most wom en wh o worry ab ou t
wh o gave b irth to a h ealth y in an t 2 weeks dep ression n ever exp erien ce it.”
ago, rep orts th at h e ou n d h er sh akin g th e (F) “Som e dep ression is com m on a ter
in an t to stop it rom cryin g. Wh en th e ch ildb irth .”
d octor qu estion s th e wom an ab ou t th e
in cid en t, sh e says “I d id n ot realize it wou ld 13. Th e m oth er o a 3-year-old ch ild tells
b e so m u ch work.” Th e p atien t also rep orts th e doctor th at, alth ou gh sh e in stru cts th e
th at sh e wakes u p at 5 a m every day an d ch ild to sit still at th e din n er table, th e ch ild
can n ot all back asleep an d h as very little can n ot seem to d o so or m ore th an 10
ap p etite. Th e n ext step in m an agem en t is or m in u tes at a tim e. Sh e squ irm s in h er seat
th e doctor to an d gets ou t o h er ch air. Th e ch ild’s m otor
an d verbal skills are ap p rop riate or h er age.
(A) assess th e p atien t or th ou gh ts o su icid e
Wh ich o th e ollowin g best f ts th is p ictu re?
(B) advise th e ath er to h ire a caregiver to
assist th e m oth er in carin g or th e ch ild (A) Sep aration an xiety disorder
(C) set u p an oth er ap p oin tm en t or th e (B) Typ ical beh avior
ollowin g week (C) Delayed develop m en t
(D) p rescribe an an tidep ressan t (D) Lack o basic tru st
(E) tell th e ath er th at th e m oth er is sh owin g (E) Atten tion de icit h yp eractivity disorder
evid en ce o th e “b aby blu es” (ADHD)
10 BRS Behavioral Science
14. A typ ical 8-m on th -old ch ild is b rou gh t to 17. Th e m oth er o a 1-m on th -old ch ild, h er
th e p ediatrician or h is m on th ly well-baby secon d, is con cern ed becau se th e baby cries
exam in ation . Th e ch ild is th e am ily’s f rst, every day rom 6 p m to 7 pm . Sh e tells th e
an d h e is cared or at h om e by h is m oth er. doctor th at, u n like h er f rst ch ild wh o was
Wh en th e doctor ap p roach es th e ch ild in h is always calm , n oth in g sh e does d u rin g th is
m oth er’s arm s, th e ch ild’s beh avior is m ost h ou r seem s to com ort th is baby. Ph ysical
likely to b e ch aracterized by exam in ation is u n rem arkable, an d th e
(A) with drawal rom th e doctor ch ild h as gain ed 2 p ou n d s sin ce b irth . With
(B) sm ilin g at th e d octor resp ect to th e m oth er, th e p h ysician sh ou ld
(C) in di eren ce to th e doctor (A) reassu re h er th at all ch ildren are di eren t
(D) an an ticip atory p ostu re toward th e an d th at som e cryin g is n orm al
doctor (arm s h eld ou t to b e p icked u p ) (B) recom m en d th at sh e see a
(E) with drawal rom both th e doctor an d th e p sych oth erap ist
m oth er (C) p rescribe an an tidep ressan t
(D) recom m en d th at th e ath er care or th e
15. Wh ile sh e p reviou sly slep t in h er own ch ild wh en it is cryin g
bed, a ter h er p aren ts’ d ivorce, a 5-year- (E) re er h er to a p ediatrician sp ecializin g in
old girl begs to be allowed to sleep in h er “di icu lt” in an ts
m oth er’s bed every n igh t. Sh e says th at a
“robb er” is u n der h er bed. Sh e con tin u es 18. A 4-year-old boy survives a h ouse f re
to do well in kin dergarten an d to p lay with in wh ich his ath er was killed. The ch ild has
h er rien d s. Th e b est d escrip tion o th is girl’s n o visible in juries an d m edical evalu ation
behavior is is un rem arkable. Alth ough he has been told
(A) sep aration an xiety d isorder th at his ath er h as died, in the weeks a ter th e
(B) typ ical beh avior with regression f re, th e ch ild con tin ues to ask or h is ather.
(C) delayed develop m en t Th e best explan ation or th is boy’s behavior is
(D) lack o basic tru st (A) an acu te reaction to severe stress
(E) ADHD (B) a typ ical reaction or h is age
(C) delayed develop m en t
16. A 2-year-old girl wh o h as been in (D) re u sal to believe th e tru th
oster care sin ce b irth is very rien d ly an d (E) an u n d iagn osed h ead in ju ry
a ection ate with stran gers. Sh e p u ts h er
arm s ou t to th em to be p icked u p an d
th en “cu dd les u p” to th em . Th e oster Questions 19–24
m oth er states th at th e ch ild h as “beh avior
p roblem s” an d th en n otes th at sh e h as n ever For each develop m en tal m ileston e, select th e
elt “close” to th e ch ild . Th e m ost likely age at wh ich it com m on ly irst ap p ears.
exp lan ation or th is ch ild’s b eh avior toward
stran gers is 19. Tran s ers toys rom on e h an d to th e
oth er.
(A) typ ical beh avior
(B) Rett’s d isord er (A) 0–3 m on th s
(C) reactive attach m en t d isord er (B) 4–6 m on th s
(D) disin h ib ited social en gagem en t (C) 7–11 m on th s
disord er (D) 12–15 m on th s
(E) m ild au tism sp ectru m disorder (E) 16–30 m on th s
Chapter 1 The Beginning of Life: Pregnancy Through Preschool 11
1. The answer is C. Th e p aren ts sh ou ld b e reassu red th at like th eir ch ild , 13-m on th -old
ch ild ren typ ically say on ly a ew word s an d are ju st startin g to walk. Ch ildren typ ically sh ow
n o in terest in n or can th ey be toilet train ed u n til th ey are at least 2½ –3 years o age.
2. The answer is C. Th e m ajor ob jective o h earin g loss screen in g in n ewborn s is or early
diagn osis an d treatm en t o h earin g loss in ord er to p reven t lan gu age develop m en t delay.
In older ch ild ren , evalu ation o h earin g loss is u se u l in determ in e th e n ecessity o u sin g
coch lear im p lan ts or sp eech th erapy. Hearin g loss is n ot sp eci ically associated with m otor
develop m en t delay.
3. The answer is B. Most ch ild ren are toilet train ed by th e age o 5 years. However, bed wettin g
in a 5-year-old wh o h as n ever been toilet train ed an d is oth erwise develop in g ap p rop riately
is m ost likely to be a resu lt o p h ysiological im m atu rity, p robably related to gen etic
actors, or exam ple, th e ath er was also a bed wetter. Em otion al stress, sexu al abu se, an d
dep ression are less likely to b e th e cau se o bed wettin g in a ch ild wh o h as n ever been toilet
train ed, alth ou gh th ey can lead to b ed wettin g in a p reviou sly toilet-train ed ch ild. Absen ce
o m ed ical in d in gs in dicates th at th is ch ild is u n likely to h ave a u rin ary tract in ection .
4. The answer is D. Th is ch ild is likely to sh ow reactive attach m en t disord er a ter th is
p rolon ged sep aration rom h is m oth er. Alth ou gh th e orp h an age is well kep t, it is u n likely
th e ch ild h as b een able to orm a stab le attach m en t to an oth er caretaker b ecau se o th e h igh
n u m ber o sta ch an ges. Lou d p rotests occu r in itially wh en th e m oth er leaves th e ch ild.
With h er con tin ued absen ce, th is ch ild exp erien ces oth er seriou s reaction s. Th ese reaction s
in clu d e d ep ression , d ecreased resp on siven ess to adu lts, an d de icits in th e develop m en t o
social an d m otor skills.
5. The answer is A. Two-year-old ch ild ren sp eak in two-word sen ten ces (e.g., “Me go”). Toilet
train in g or th e ability to sp en d m ost o th e d ay away rom th e m oth er does n ot u su ally occu r
u n til age 3. Ch ildren en gage in coop erative p lay startin g at abou t age 4 an d can ride a th ree-
wh eeled b icycle at ab ou t age 3.
6. The answer is A. At th e age o 3 years, th e ch ild can ride a tricycle, copy a circle, an d en gage
in p arallel p lay (p lay alon gside bu t n ot coop eratively with oth er ch ildren ). However, 3-year-
old ch ild ren su ch as th is on e sh ou ld h ave a vocabu lary o abou t 900 words an d sp eak in
com p lete sen ten ces.
7. The answer is B. Th e social sm ile (sm ilin g in resp on se to seein g a h u m an ace) is on e o th e
irst develop m en tal m ileston es to ap p ear in th e in an t an d is p resen t by 1–2 m on th s o age.
Stran ger an xiety ( ear o u n am iliar p eop le) ap p ears at abou t 7 m on th s o age an d in dicates
th at th e in an t h as a sp eci ic attach m en t to th e m oth er. Rap p roch em en t (th e ten den cy to
ru n away rom th e m oth er an d th en ru n back or com ort an d reassu ran ce) ap p ears at abou t
18 m on th s o age. Core gen der iden tity (th e sen se o sel as m ale or em ale) is establish ed
between 2 an d 3 years o age. Tran sien t p h ob ias (irration al ears) occu r in typ ical ch ildren ,
ap p earin g m ost com m on ly at 4–5 years o age.
12
Chapter 1 The Beginning of Life: Pregnancy Through Preschool 13
8. The answer is C. In 2010, th e overall in an t m ortality rate in th e Un ited States was 6.14 p er
1,000 live birth s. Th is rate, wh ich is closely associated with socioecon om ic statu s, was at
least two tim es h igh er in A rican -Am erican in an ts th an in Wh ite in an ts.
9. The answer is E. Th e m ost im p ortan t p sych ological task o in an cy is th e develop m en t
o an in tim ate attach m en t to th e m oth er or p rim ary caregiver. Stran ger an xiety, wh ich
typ ically ap p ears at ab ou t 7 m on th s o age, dem on strates th at th e ch ild h as develop ed
th is attach m en t an d can d istin gu ish its m oth er rom oth ers. Sp eech , th e ab ility to th in k
logically, an d th e d evelop m en t o a con scien ce are skills th at are develop ed later du rin g
ch ildh ood.
10. The answer is A. Th is wom an is sh owin g evid en ce o a seriou s p ostp artu m reaction su ch
as m ajor dep ression , n ot sim p ly th e “b aby b lu es.” Becau se sh e sh ows sign s o d ep ression ,
or exam p le, early m orn in g awaken in g an d lack o ap p etite, th e n ext step in m an agem en t
is to assess h er or th ou gh ts o su icide. Th e ch ild m u st also be p rotected. I sh e is su icidal
or likely to h arm th e ch ild , in p atien t treatm en t m ay b e in dicated. Ultim ately, assistan ce
with care o th e child m ay be h elp u l, bu t th e irst step is to p rotect th e p atien t an d th e
ch ild. Ju st settin g u p an oth er ap p oin tm en t or th e ollowin g week or p rescrib in g an
an tid ep ressan t will n ot p rotect eith er.
11. The answer is E. Postp artu m blu es m ay occu r in on e-th ird to on e-h al o n ew m oth ers an d
can last u p to 2 weeks. In terven tion in volves su p p ort an d p ractical h elp with th e ch ild.
Brie p sych otic d isord er is rare, occu rrin g in less th an 1% o n ew m oth ers an d lastin g u p to
1 m on th a ter ch ild birth . Postp artu m d ep ression occu rs in 5%–10% o n ew m oth ers an d is
treated p rim arily with an tid ep ressan t m edication .
12. The answer is C. “Did you exp erien ce an y em otion al di icu lties a ter th e birth o you r
oth er ch ildren ?” is an im p ortan t qu estion sin ce a p red ictor o p ostp artu m reaction s is
wh eth er or n ot they h ave occu rred be ore. Th is p atien t is p robably worried becau se sh e
h as h ad p reviou s p roblem s. Reassu rin g statem en ts, su ch as “Most wom en wh o worry
abou t d ep ression n ever exp erien ce it,” “Do n ot worry, th ere are m an y e ective m edication s
or dep ression ,” “Wom en o ten becom e m ore an xiou s toward th e en d o th eir p regn an cy,”
or “Som e dep ression is com m on a ter ch ildb irth ,” do n ot ad d ress th is p atien t’s realistic
con cern s.
13. The answer is B. It is typ ical or a 3-year-old ch ild to h ave di icu lty sittin g still or an y
len gth o tim e. By sch ool age, ch ild ren sh ou ld be able to sit still an d p ay atten tion or
lon ger p eriod s o tim e. Th u s, th is is n ot ADHD. Th ere is also n o eviden ce o delayed
develop m en t, lack o b asic tru st, or sep aration an xiety disorder.
14. The answer is A. Stran ger an xiety (th e ten den cy to cry an d with draw in th e p resen ce o an
u n am iliar p erson ) develop s in typ ical in an ts at 7–9 m on th s o age. It does n ot in dicate
th at th e ch ild is develop m en tally d elayed , em otion ally distu rbed, or th at th e ch ild h as
been ab u sed b u t rath er th at th e ch ild can n ow d istin gu ish am iliar rom u n am iliar p eop le.
Stran ger an xiety is m ore com m on in ch ildren wh o are cared or by on ly on e p erson an d is
red u ced in th ose exp osed to m an y d i eren t caregivers.
15. The answer is B. Th e b est d escrip tion o th is girl’s b eh avior is typ ical. Her desire to sleep
with h er m oth er is a sign o regression , a de en se m ech an ism th at is com m on in typ ical
ch ildren u n der stress. Becau se sh e con tin u es to p lay well wh en away rom h er m oth er, th is
is n ot sep aration an xiety d isorder. Th ere is also n o eviden ce o delayed develop m en t, lack
o b asic tru st, or ADHD (see Ch ap ter 15).
16. The answer is D. Th e m ost likely d iagn osis or th is ch ild is d isin h ib ited social en gagem en t
disord er. Ch ild ren with th is d isord er orm in discrim in ate attach m en ts to stran gers becau se
th eir p rim ary attach m en t igu re, h ere th e oster m oth er, does n ot in teract n orm ally
with th e ch ild. Mild au tism sp ectru m disorder an d Rett’s disorder are ch aracterized by
decreased , n ot in creased, social in teraction .
14 BRS Behavioral Science
17. The answer is A. Th e p h ysician sh ou ld reassu re th e m oth er th at all ch ild ren are d i eren t
an d th at som e cryin g is n orm al. Th e ch ild’s ap p rop riate weigh t gain an d n egative m edical
in din gs in dicate th at th e ch ild is develop in g typ ically. On ce th e m oth er is reassu red, it will
n ot b e n ecessary to recom m en d a p sych oth erap ist, p rescribe an an tidep ressan t, re er h er
to a p ediatrician sp ecializin g in “di icu lt” in an ts, or recom m en din g th at th e ath er care or
th e ch ild wh en it is cryin g.
18. The answer is B. Th is 4-year-old ch ild is sh owin g a typ ical reaction or h is age. Ch ildren
u n d er th e age o 6 years d o n ot u n d erstan d th e in ality o death an d u lly exp ect dead
p eop le to com e back to li e. Th at is wh y, alth ou gh h e h as been told th at h is ath er h as died,
th is ch ild rep eatedly asks or h is ath er. Wh ile h e h as been severely stressed, h e is n eith er
sim p ly re u sin g to believe th e tru th n or sh owin g delayed develop m en t. Wh ile it is p ossible
th at th is boy h as an u n diagn osed h ead in ju ry, a typ ical reaction is m ore likely.
19. The answer is C. Tran s errin g objects rom h an d to h an d com m on ly occu rs at abou t 10
m on th s o age.
20. The answer is B. In an ts can u su ally tu rn over at abou t 5 m on th s o age.
21. The answer is A. Ch ild ren b egin to sh ow social sm ilin g between 1 an d 2 m on th s o age.
22. The answer is C. Ch ildren begin to resp on d to th eir own n am es between 7 an d 11 m on th s
o age.
23. The answer is E. Ch ildren b egin to u se a u ten sil to eed th em selves at abou t 2 years o age.
24. The answer is E. Ch ildren b egin to m ake m arks (scrib b le) on p ap er at ab ou t 18 m on th s o
age.
Sch ool Age, Adolescen ce,
Sp ecial Issu es o
c ha pte r
2 Develop m en t, an d
Adu lth ood
15
16 BRS Behavioral Science
3. Un derstan ds th e con cep ts o conservation and seriation; both are n ecessary or certain
typ es o learn in g.
a. Conservation in volves th e u n derstan din g th at a qu an tity o a su bstan ce rem ain s th e
sam e regardless o th e size o th e con tain er or sh ap e it is in (e.g., two con tain ers m ay
con tain th e sam e am ou n t o water, even th ou gh on e is a tall, th in tu be an d on e is a
sh ort, wid e bowl).
b. Seriation in volves th e ab ility to arran ge objects in order with resp ect to th eir sizes or
oth er qu alities.
C. Motor development. Th e typ ical sch ool-age ch ild en gages in com p lex m otor tasks (e.g., p lays
b aseb all, skip s rop e, rid es a two-wh eeled b icycle).
2. Risk-taking behavior
a. Readin ess to ch allen ge p aren tal rules an d eelin gs o omnipotence m ay result in risk-taking
behavior (e.g., ailure to use con dom s, drivin g too ast, sm okin g cigarettes or m arijuan a).
b. Edu cation ab ou t obvious short-term benefits rath er th an re eren ces to lon g-term con se-
qu en ces o beh avior is m ore likely to decrease teenagers’ unwanted behavior. For exam -
p le, to discourage smoking cigarettes , tellin g teen agers th at th eir teeth will stay wh ite
i th ey d o n ot sm oke, or th at oth er teen s in d sm okin g d isgu stin g, will b e m ore h elp u l
th an tellin g th em th at th ey will avoid lu n g can cer in 30 years.
D. Teenage sexuality
1. In th e Un ited States, first sexual intercourse occu rs on average at 16 years o age; by 19
years o age, m ost m en an d wom en h ave h ad sexu al in tercou rse.
2. Fewer th an h al o all sexu ally active teen agers do not use contraceptives or reason s th at
in clu d e th e con viction th at th ey will n ot get p regn an t, lack o access to con tracep tives,
an d lack o ed u cation ab ou t wh ich m eth ods are m ost e ective.
3. Ph ysician s m ay cou n sel m in ors (p erson s u n der 18 years o age) an d p rovide th em with
con tracep tives with ou t p aren tal kn owledge or con sen t. Th ey m ay also p rovide to m in ors
treatm en t or sexu ally tran sm itted diseases, p roblem s associated with p regn an cy, an d
dru g an d alcoh ol ab u se (see Ch ap ter 23).
4. Becau se o th eir p oten tial sen sitivity, issu es in volvin g sexu ality an d dru g abu se, as well as
issu es con cern in g p h ysical ap p earan ce su ch as obesity, are typ ically discu ssed with teen -
agers without a parent present. Ph ysical exam in ation is d on e with ou t a p aren t p resen t b u t
with a chaperone p resen t.
E. Teenage pregnancy
1. Teen age p regn an cy is a social p roblem in th e Un ited States, alth ou gh th e birth rate and
abortion rate in Am erican teen agers have been declining. In con trast, th e birth rate am on g
wom en 35–44 h as been in creasin g (Figu re 2.1).
200 200
p
25–29
u
o
r
100 100
g
e
20–24
g
30–34
a
50 50
d
e
i
f
i
c
e
35–39 15–19
p
s
n
i
40–44
n
10
e
10
m
o
w
5 5
0
0
0
,
1
FIGURE 2.1. Birth rates in the United States by selected age of mother:
r
e
Final 1990–2012 and preliminary 2013. (Reprinted from Hamilton BE,
p
e
Martin J A, Osterman MJ K, et al. Division of Vital Statistics. Births:
t
a
R
Preliminary data for 2013. Natl Vital Stat Rep. 2014;63(2).) Rates are 1 1
plotted on a logarithmic scale. 1990 1995 2000 2005 2010 2013
18 BRS Behavioral Science
B. Adoption
1. An adoptive parent is a p erson wh o volu n tarily becom es th e legal parent o a ch ild wh o is
n ot h is or h er gen etic o sp rin g.
2. Adop ted ch ild ren , p articu larly th ose adop ted a ter in an cy, m ay b e at in creased risk or
beh avioral p rob lem s in ch ild h ood an d ad olescen ce.
3. Ch ild ren should be told by th eir p aren ts th at th ey are ad op ted at the earliest age possible to
avoid th e ch an ce o oth ers tellin g th em irst.
C. Intellectual disability
1. Etiology
a. Th e m ost com m on gen etic cau ses o in tellectu al disability are Down’s syndrome and
fragile X syndrome .
b. Oth er cau ses in clu de m etabolic actors a ectin g th e m oth er or etu s, p ren atal an d
p ostn atal infection (e.g., ru bella), an d maternal substance use ; m an y cases o in tellec-
tu al disability are o u n kn own etiology.
2. Mildly an d m oderately in tellectu ally disab led ch ildren an d adolescen ts com m on ly know
they are different (see Ch ap ter 8). Becau se o th is, th ey m ay b ecom e frustrated and socially
withdrawn. Th ey m ay h ave p oor sel -esteem becau se it is di icu lt or th em to com m u n i-
cate an d com p ete with p eers.
3. Th e Vineland Social Maturity Scale (see Ch ap ter 8) can b e u sed to evalu ate social skills an d
skills or d aily livin g in in tellectu ally d isabled an d oth er ch allen ged in dividu als.
4. Avoidance of pregnancy in adu lts with in tellectu al disabilities can becom e an issu e, p ar-
ticu larly in resid en tial social settin gs (e.g., su m m er cam p ). Long-acting, reversible contra-
ceptive methods su ch as su bcu tan eou s p rogesteron e im p lan ts can be p articu larly u se u l
to th ese in dividu als.
Chapter 2 School Age, Adolescence, Special Issues of Development, and Adulthood 19
B. Responsibilities. Th e in d ivid u al eith er m ain tain s a con tin u ed sen se o p rodu ctivity or devel-
op s a sen se o em p tin ess (Erikson’s stage o gen erativity vs. stagn ation ).
C. Relationships
1. Man y m en in th eir m iddle 40s or early 50s exh ibit a midlife crisis . Th is m ay lead to:
a. A ch an ge in p ro ession or li estyle.
b. In id elity, sep aration , or d ivorce.
c. In creased u se o alcoh ol or oth er d ru gs.
d. Dep ression .
2. Midli e crisis is associated with an awareness of one’s own aging an d death an d severe or
u n exp ected li estyle ch an ges (e.g., death o a sp ou se, loss o a job, seriou s illn ess).
8. A ch ild’s p et h as recen tly died . Th e ch ild 12. A wom an an d her 15-year-old daughter
believes th at th e p et will soon com e b ack to p resen t to the physician’s o f ce together. The
li e. Th is ch ild is m ost likely to be o age m other asks the physician to f t her daughter
(A) 4 years or a diaphragm . The m ost appropriate action
(B) 6 years or the p hysician to take at this tim e is to
(C) 7 years (A) ollow th e m oth er’s wish es
(D) 9 years (B) ask th e m oth er wh y sh e wan ts a
(E) 11 years diap h ragm or h er d au gh ter
(C) recom m en d th at th e girl see a cou n selor
9. A 10-year-old girl with Down’s syn drom e (D) ask to sp eak to th e girl alon e
an d an IQ o 60 is b rou gh t to th e p h ysician’s (E) ask th e girl i sh e is sexu ally active
o f ce or a sch ool p h ysical. Wh en th e doctor
in terviews th is girl, h e is m ost likely to f n d 13. A p h ysician is asked to evalu ate th e
th at sh e develop m en t o an 11-year-old girl. Wh ich
(A) h as good sel -esteem o the ollowin g m ileston es is u su ally n ot
(B) kn ows th at sh e is develop m en tally acquired u n til a ter th e age o 11 years?
delayed (A) Th e con cep t o seriation
(C) com m u n icates well with p eers (B) Th e con cep t o con servation
(D) com p etes su ccess u lly with p eers (C) Parallel p lay
(E) is socially ou tgoin g (D) Th e orm ation o a p erson al iden tity
(E) An u n d erstan d in g o th e con cep t o “ air
10. A 15-year-old boy tells h is p h ysician th at p lay”
h e h as b een sm okin g cigarettes or th e p ast
year. He relates th at h is rien d s sm oke an d 14. A girl tells h er m oth er th at sh e “h ates th e
h is ath er sm okes. Th e m ost likely reason boys becau se th ey are n oisy an d stu p id.” Th e
th at th is teen ager d oes n ot attem p t to stop age o th is girl is m ost likely to be
sm okin g is becau se (A) 4 years
(A) h e is dep ressed (B) 6 years
(B) h is ath er sm okes (C) 9 years
(C) h is p eers sm oke (D) 13 years
(D) h e does n ot kn ow th at sm okin g is (E) 15 years
h arm u l
(E) sm okin g is add ictive 15. At the lun ch table, a ch ild asks h is m oth er
to cut h is h ot d og u p in to th ree p ieces so th at
11. A orm erly ou tgoin g 10-year-old b oy h e can have three tim es as m uch to eat. Th e
b egin s to d o p oorly in sch ool a ter h is 6-year- age o th is ch ild is m ost likely to be
old broth er is diagn osed with leu kem ia. He (A) 4 years
n ow p re ers to watch television alon e in h is (B) 6 years
room an d d oes n ot wan t to socialize with (C) 9 years
h is rien d s. His p aren ts are very stressed (D) 13 years
by carin g or th e you n ger ch ild b u t d o (E) 15 years
n ot ask th e old er ch ild or h elp. Th e m ost
ap prop riate su ggestion or th e doctor to 16. A 15-year-old overweigh t girl an d h er
m ake with resp ect to th e 10-year-old is to tell m oth er com e to see th e doctor or advice
th e p aren ts to abou t diet an d exercise. Th e m oth er states
(A) in sist th at h e take m ore resp on sibility or th at sh e d oes n ot kn ow wh y th e girl is
carin g or h is you n ger broth er overweigh t becau se sh e cooks th e sam e ood
(B) ign ore h is beh avior or her an d h er slim 16-year-old broth er. Th e
(C) rem ove th e television rom h is room doctor sh ou ld f rst
(D) p ay m ore atten tion to h im (A) talk to th e m oth er alon e
(E) tell h im n ot to worry, everyth in g will b e (B) talk to both th e teen s with th e m oth er
in e p resen t
(C) talk to th e girl with th e m oth er p resen t
(D) talk to th e m oth er, th e broth er, an d th e
girl togeth er
(E) talk to th e girl alon e
22 BRS Behavioral Science
17. A m ed ical stu den t on a su rgery rotation 19. A m oth er worried ly rep orts th at h er
is assign ed to stay with a 9-year-old girl wh o 7-year-old son is o ten dirty wh en h e com es
is waitin g to h ave su rgery to rep air a cle t in rom p layin g. Sh e n otes th at h e d igs in
p alate. Th e girl, wh o h as recen tly arrived th e dirt, wip es h is ace with h is d irty h an d s,
alon e rom Laos, does n ot sp eak En glish an d an d clim bs trees ou tside o th e h om e. Sh e
ap pears an xiou s. Th e h osp ital adm in istrator states th at sh e is worried th at h e will catch
h as requ ested a tran slator wh o h as n ot yet a disease or in ju re h im sel . Th e m oth er also
arrived. At th is tim e, th e m ost ap p rop riate rep orts th at sh e h ad a m eetin g with th e
action or th e m edical stu den t to take is to ch ild’s teach er wh o told h er th at th e ch ild
(A) sedate th e ch ild to d ecrease h er an xiety is doin g well in sch ool. Th e n ext step in
(B) give th e ch ild a toy to keep h er occu p ied m an agem en t is or th e doctor to
(C) su ggest th at th e n u rse stay with th e ch ild (A) sp eak with th e ch ild’s teach er
so th at h e can review h er ch art (B) sp eak with th e ch ild
(D) look in th e ch ild’s ears with an otoscop e (C) say “He m u st be h ard to h an d le”
(E) listen to th e ch ild’s h eart with a (D) say “Tell m e m ore abou t you r con cern s
steth oscop e an d th en let th e ch ild try regardin g you r son ?”
u sin g th e steth oscop e to listen to h is (E) say “He is in e, d o n ot worry”
h eart
1. The answer is B. Sayin g “Let’s talk abou t th e p ros an d con s o gettin g a tattoo” will
en cou rage th e girl to talk abou t h er m otivation or gettin g th e tattoo. Th e cu rren t risk o
gettin g th e tattoo or p roblem s with rem oval o th e tattoo in th e u tu re p robably are n ot as
im p ortan t at th is tim e as wh y sh e wan ts it so badly. Sayin g “I stron gly recom m en d th at you
n ot get th e tattoo” or criticizin g h er by sayin g “I you kn ow th ere are risks, wh y do you wan t
th e tattoo?” will n ot b e e ective. Ju st givin g h er a broch u re also will n ot be h elp u l; m ost
likely it will be ign ored.
2. The answer is B. Teen agers wh o becom e p regn an t requ en tly are dep ressed, com e rom
h om es wh ere th e p aren ts are d ivorced, h ave p roblem s in sch ool, an d m ay n ot kn ow abou t
e ective con tracep tive m eth od s. Stu d ies h ave n ot in dicated th at livin g in a ru ral area is
related to teen age p regn an cy.
3. The answer is C. Wh ile m idli e is associated with th e p ossession o p ower an d au th ority,
p h ysical abilities declin e. Th is tim e o li e is also associated with a m idli e crisis, wh ich m ay
in clu de in creased alcoh ol an d dru g u se as well as an in creased likelih ood o ch an ges in
social an d work relation sh ip s.
4. The answer is C. Th ese 52-year-old wom en in good gen eral h ealth are goin g th rou gh
m en op au se. Th e m ost com m on sym p tom o m en op au se occu rrin g cross-cu ltu rally is
h ot lash es, a p u rely p h ysiological p h en om en on . In m ost wom en , m en op au se is n ot
ch aracterized by p sych op ath ology su ch as severe dep ression or an xiety or p h ysical
sym p tom s like atigu e an d leth argy.
5. The answer is D. In crease in p en is width , develop m en t o th e glan s, an d darken in g o scrotal
skin ch aracterize Tan n er stage 4. Stage 1 is ch aracterized by sligh t elevation o th e p ap illae,
an d stage 2 by th e p resen ce o scan t, straigh t p u bic h air, testes en largem en t, develop m en t
o textu re in scrotal skin , an d sligh t elevation o breast tissu e. In stage 3, p u bic h air in creases
over th e p u b is an d becom es cu rly, an d th e p en is in creases in len gth ; in stage 5, m ale an d
em ale gen italia are m u ch like th ose o adu lts.
6. The answer is C. Th e age o th is wom an’s son is m ost likely to be 15 years. Middle
adolescen ts (15–17 years) o ten ch allen ge p aren tal auth ority an d h ave eelin gs o
om n ip oten ce (e.g., n oth in g bad will h ap p en to th em becau se th ey are all p ower u l). You n ger
adolescen ts (11–14 years) are u n likely to ch allen ge p aren tal rules an d au th ority. Older
adolescen ts (18–20 years) h ave develop ed sel -con trol an d a m ore realistic p ictu re o th eir
own abilities.
7. The answer is D. Wh en com p ared to you n ger ages, p eers an d n on am ilial adu lts becom e
m ore im p ortan t to th e laten cy-age ch ild an d th e am ily becom es less im p ortan t. Ch ildren
7–11 years o age h ave th e cap acity or logical th ou gh t, h ave a con scien ce, iden ti y with th e
sam e-sex p aren t, an d sh ow a stron g p re eren ce or p laym ates o th eir own sex.
8. The answer is A. Presch ool ch ildren u su ally can n ot com p reh en d th e m ean in g o death an d
com m on ly believe th at th e dead p erson or p et will com e back to li e. Ch ildren over th e age
o 6 years com m on ly are aware o th e in ality o death (see Ch ap ter 1).
23
24 BRS Behavioral Science
9. The answer is B. Mild ly an d m od erately in tellectu ally disab led ch ild ren are aware th at th ey
h ave a d evelop m en tal d elay. Th ey o ten h ave low sel -esteem an d m ay becom e socially
with drawn . In p art, th ese p roblem s occu r becau se th ey h ave di icu lty com m u n icatin g
with an d com p etin g with p eers.
10. The answer is C. Peer p ressu re h as a m ajor in lu en ce on th e b eh avior o ad olescen ts wh o
ten d to do wh at oth er adolescen ts are doin g. Dep ression , th e sm okin g beh avior o th eir
p aren ts, an d th e ad d ictive qu ality o cigarettes h ave less o an in lu en ce. Most teen agers
h ave been ed u cated with resp ect to th e d an gers o sm okin g.
11. The answer is D. The doctor should rem ind the parents to pay m ore attention to the older
child. The child is likely to be righten ed by his younger sibling’s illness and the attitudes o
his paren ts toward the youn ger child. School-age children such as this one m ay becom e
withdrawn or “act out” by showin g bad behavior when ear ul or depressed. While he can be
included in the care o his brother, it is not appropriate to insist that he take m ore responsibility
or him . Ign orin g his behavior or punishin g him can increase his ear and withdrawal. False
reassuran ce such as tellin g the child that everything will be ine is not appropriate.
12. The answer is D. Th e m ost ap p rop riate action or th e p h ysician to take at th is tim e is to ask
to sp eak to th e girl alon e. Th e p h ysician can th en ask th e girl abou t h er sexu al activity an d
p rovid e con tracep tives an d cou n selin g i sh e wish es, with ou t n oti ication or con sen t rom
th e m oth er. Th e m oth er’s wish es in th is circu m stan ce are n ot relevan t to th e p h ysician’s
action ; th e teen ager is th e p atien t.
13. The answer is D. Th e orm ation o a p erson al id en tity is u su ally ach ieved d u rin g th e
teen age years. Th e con cep ts o seriation an d con servation an d an u n derstan din g o th e
con cep t o “ air p lay” are gain ed du rin g th e sch ool-age years. Parallel p lay is u su ally seen
between ages 2 an d 4 years.
14. The answer is C. Laten cy-age ch ild ren (age 7–11 years) h ave little in terest in th ose o th e
op p osite sex an d o ten criticize or avoid th em . In con trast, you n ger ch ildren do n ot sh ow
stron g gen der p re eren ces or p laym ates, an d teen agers com m on ly seek th e com p an y o
op p osite-sex p eers.
15. The answer is A. Th is ch ild is m ost likely to b e 4 years o age. Presch ool ch ildren do n ot yet
u n d erstan d th e con cep t o con servation (i.e., th at th e qu an tity o a su bstan ce rem ain s th e
sam e regard less o th e sh ap e th at it is in ). Th u s, th is ch ild believes th at a h ot dog cu t in to
th ree p ieces h as m ore in it th an wh en it was in on ly on e p iece. Ch ildren u n derstan d th is
con cep t better as th ey ap p roach sch ool age.
16. The answer is E. As in Qu estion 12, th e p h ysician sh ou ld talk to th is 15-year-old girl alon e.
In ad dition to sexu al an d d ru g u se issu es, th ose th at in volve body im age su ch as body
weigh t ideally sh ou ld be discu ssed with a teen ager alon e, with ou t oth er am ily m em bers
p resen t.
17. The answer is E. Th e b est th in g or th e m edical stu d en t to do at th is tim e is to in teract
with th e ch ild . Sin ce th ey d o n ot sp eak th e sam e lan gu age, in volvin g ch ildren o th is age
in an in teractive activity su ch as u sin g th e steth oscop e or drawin g p ictu res togeth er is th e
b est ch oice h ere. Neith er givin g th e ch ild a toy n or lookin g in h er ears is an in teractive
activity. Th e stu den t, n ot th e n u rse, is resp on sible or th e ch ild in th is in stan ce. Sedation is
in ap p rop riate at th is tim e; social activity is o ten e ective in decreasin g a p atien t’s an xiety.
18. The answer is A. Paren ts sh ou ld b e p resen t wh en a p h ysician sp eaks to a you n ger ch ild,
bu t teen agers u su ally sh ou ld b e in terviewed, p articu larly ab ou t sexu al issu es, with ou t
p aren ts p resen t. Th u s, th e d octor sh ou ld ask th e 15-year-old to leave an d talk to th e 8-year-
old with th e m oth er p resen t. Th en , th e d octor sh ou ld talk to th e 15-year-old alon e.
19. The answer is D. Alth ou gh th is boy is p robably sh owin g typical behavior or a 6-year-old,
the doctor n eeds to kn ow m ore abou t th is m other’s con cern s regardin g her son . Sin ce h e is
doin g well in sch ool; th ere is n o n eed to sp eak to th e teach er or th e ch ild. Sim p ly sayin g “he
m u st be h ard to h an dle” or “h e is in e, do n ot worry” will n ot address the m other’s con cern s.
Agin g, Death , an d
c ha pte r
3 Bereavem en t
I. AGING
A. Demographics
1. By 2020, m ore th an 15% o US p op u lation will be m ore th an 65 years o age.
2. Th e astest growin g segm en t o th e p op u lation is p eop le over age 85.
3. Di eren ces in li e exp ectan cies by gen d er an d eth n icity (Figu re 3.1) h ave been decreasin g
over th e p ast ew years.
4. Gerontology, th e stu dy o agin g, an d geriatrics , th e care o agin g p eop le, h ave becom e
im p ortan t m edical ields.
a. Geriatrician s typ ically manage rather than cure th e ch ron ic illn ess o agin g su ch as
h yp erten sion , can cer, an d d iab etes.
b. A m ajor aim o geriatrics is to keep elderly p atien ts m obile an d active. Becau se fractures
(e.g., o th e h ip ) are m ore likely th an ch ron ic illn ess to cau se loss of mobility lead in g to
disab ility an d d eath in th e elderly, preventing falls an d p reven tion an d m an agem en t o
osteoporosis are im p ortan t oci in m an agem en t.
c. Preven tion an d m an agem en t o osteop orosis in clu des in creasin g weight-bearing exer-
cise an d in creasin g calcium an d vitamin D in th e diet. Medication s th at decrease bon e
resorp tion by b lockin g osteoclasts, or exam p le, alendronate sodium (Fosam ax), or
in crease bon e orm ation by stim u latin g osteoblasts, or exam p le, teriparatide (Forteo),
are also u se u l.
25
26 BRS Behavioral Science
85 Fe ma le 83.8
y)
81.0 Ma le 81.1
(
h
80 77.7 78.5
t
r
i
76.2 76.4
b
t
75
a
y
71.4
c
n
a
70
t
c
e
xp
65
e
e
f
i
L
60 FIGURE 3.1. Life expectancy at birth in years in the
All Africa n White His pa nic United States by selected characteristics in 2010.
Ame rica n Ame rica n (Data from National Center for Health Statistics,
Ethnicity 2013.)
C. Cognitive changes
1. Alth ou gh learn in g sp eed m ay decrease, in th e absen ce o b rain d isease, intelligence
remains approximately the same th rou gh ou t li e.
2. Some memory problems m ay occu r in n orm al agin g (e.g., th e p atien t m ay orget th e n am e
o a n ew acqu ain tan ce). However, th ese p rob lem s do not interfere with the patient’s func-
tioning or ab ility to live in dep en d en tly.
D. Psychological changes
1. In late adu lth ood, th ere is eith er a sen se o ego in tegrity (i.e., satis action an d p ride in
on e’s p ast accom p lish m en ts) or a sen se o d esp air an d worth lessn ess (Erikson’s stage of
ego integrity vs. despair). Most eld erly p eop le ach ieve ego in tegrity.
2. Psych op ath ology an d related p roblem s
a. Depression is th e m ost com m on p sych iatric disorder in th e elderly. Su icide is m ore
com m on in th e eld erly th an in th e gen eral p op u lation (see Tab le 12.2).
(1) Factors associated with dep ression in th e elderly in clu de loss o sp ou se, oth er am -
ily m em bers, an d rien ds; decreased social statu s; an d declin e o h ealth .
(2) Depression may mimic and thus be misdiagnosed as Alzheimer’s disease. Th is m is-
d iagn osed d isorder is re erred to as pseudodementia becau se it o ten is associated
with m em ory loss an d cogn itive p rob lem s (see Ch ap ter 14).
(3) Dep ression can be managed successfully u sin g su p p ortive p sych oth erapy in con -
ju n ction with p h arm acoth erapy or electrocon vu lsive th erapy (see Ch ap ter 15).
b. Sleep patterns change , resultin g in loss o sleep, poor sleep quality, or both (see Chapter 10).
Chapter 3 Aging, Death, and Bereavement 27
c. Anxiety an d ear u ln ess m ay be associated with realistic ear-in du cin g situ ation s (e.g.,
worries ab ou t d evelop in g a p h ysical illn ess or allin g an d breakin g a bon e).
d. Alcohol-related disorders are o ten u n iden ti ied bu t are p resen t in 10%–15% o th e geri-
atric p op u lation .
e. Psychoactive agents m ay p rodu ce di eren t e ects in th e elderly than in you n ger
p atien ts. For exam p le, u sin g an tih istam in es su ch as dip h en hydram in e as sleep agen ts
sh ou ld be avoided becau se th ey m ay cau se delirium (see Ch ap ter 14) in elderly p atien ts.
f. For a realistic p ictu re o th e u n ction in g level o elderly p atien ts, th e p h ysician sh ou ld
ideally evaluate patients in familiar surroundings , su ch as th eir own h om es.
B. Anger. Th e p atien t m ay b ecom e an gry at th e p h ysician an d h osp ital sta . (“It is you r au lt
th at I am d yin g. You sh ou ld h ave ch ecked on m e weekly.”) Ph ysician s m u st learn n ot to take
su ch com m en ts p erson ally (see Ch ap ter 21).
C. Bargaining. Th e p atien t m ay try to strike a b argain with God or som e h igh er b ein g. (“I will
give h al o m y m on ey to ch arity i I can get rid o th is disease.”)
D. Depression. Th e p atien t becom es p reoccu p ied with d eath an d m ay b ecom e em otion ally
detach ed. (“I eel so distan t rom oth ers an d so h op eless.”) Som e p eop le becom e “stu ck” in
th is stage an d m ay be diagn osed with a com p licated grie reaction (see below).
t a b l e 3.1 Comparison between Normal Grief Reactions and Complicated Grief Reactions
Minor weight loss (e.g., <5 pounds) Significant weight loss (e.g., >5% of body weight)
Minor sleep disturbances Significant sleep disturbances
Mild guilty feelings Intense feelings of guilt and worthlessness
Illusions Hallucinations or delusions (see Chapter 11)
Attempts to return to work and social activities Resumes few, if any, work or social activities
Cries and expresses sadness Considers or attempts suicide
Severe symptoms resolve within 2 mo Severe symptoms persist for >2 mo
Moderate symptoms subside within 1 y Moderate symptoms persist for >1 y
Management includes increased calls and visits to the Management includes antidepressants, antipsychotics,
physician, grief peer support groups, and short-acting electroconvulsive therapy, as well as increased contact
sleep agents, e.g., zolpidem (Ambien) for transient with the physician
problems with sleep
Adapted from Fadem B. Behavioral Science in Medicine. 2nd ed. Baltimore, MD: Lippincott Williams & Wilkins; 2012.
1. When question ed about her li estyle, a 4. A term in ally ill p atien t wh o u ses a
70-year-old wom an tells the doctor that she statem en t su ch as, “It is th e doctor’s
eats m ain ly sh an d chicken but en joys an ault th at I becam e ill; sh e didn’t do an
occasion al steak. She also n otes that she is electrocardiogram wh en I cam e or m y last
lactose in toleran t an d so avoids m ilk products o ce visit,” is m ost likely in wh ich stage o
but eats alm on ds, bean s, an d can n ed salm on dyin g, accordin g to Elizabeth Kü b ler-Ross?
with bon es daily. She also n otes that she drin ks (A) Den ial
on e cup o co ee an d on e glass o win e an d (B) An ger
sm okes on e cigarette daily. To help preven t (C) Bargain in g
osteoporosis, the m ost im portan t advice the (D) Dep ression
physician should give this patient is to (E) Accep tan ce
(A) stop drin kin g win e
(B) stop eatin g steak 5. A p h ysician con d u cts a p h ysical
(C) stop drin kin g co ee exam in ation on an active, in dep en den t
(D) start u sin g d airy p rodu cts d esp ite h er 75-year-old wom an . Wh ich o th e ollowin g
in toleran ce n din gs is m ost likely?
(E) stop sm okin g (A) In creased im m u n e resp on se
(B) In creased m u scle m ass
2. An 80-year-old wom an is bein g exam in ed (C) Decreased size o brain ven tricles
by a p h ysician or ad m ission to a n u rsin g (D) Decreased bladd er con trol
h om e. Th e wom an , wh o was brou gh t to (E) Severe m em ory p roblem s
th e doctor by h er son , seem s an xiou s an d
con u sed. Th e m ost e ective action or th e 6. Nin ety p ercen t o th e p atien ts in a
p h ysician to take at th is tim e is to p rim ary care p h ysician’s p ractice are over 65
(A) arran ge or im m ed iate ad m ission to a years o age. Wh en com p ared to th e gen eral
n u rsin g h om e p opu lation , th ese elderly p atien ts are
(B) con d u ct a n eu rop sych ological evalu ation m ore likely to sh ow wh ich o th e ollowin g
(C) su ggest im m ed iate h osp italization p sych ological ch aracteristics?
(D) ask th e son i h e h as ob served ch an ges in (A) Lower likelih ood o su icide
th e p atien t’s beh avior (B) Less an xiety
(E) arran ge to exam in e th e wom an in h er (C) Lower in telligen ce
own h om e (D) Poorer sleep qu ality
(E) Less dep ression
3. Each year d u rin g th e rst week in May,
a 63-year-old wom an develop s ch est 7. Th e 78-year-old h u sban d o a 70-year-
discom ort an d a eelin g o oreb odin g. Her old wom an h as ju st died . I th is wom an
h u sb an d died 5 years ago d u rin g th e rst experien ces n orm al bereavem en t, wh ich o
week in May. Th is wom an’s exp erien ce is th e ollowin g resp on ses wou ld be exp ected?
best describ ed as
(A) In itial loss o ap p etite
(A) an atten tion -seekin g d evice (B) Feelin gs o worth lessn ess
(B) p ath ological grie (C) Th reats o su icide
(C) an an n iversary reaction (D) In ten se grie lastin g years a ter th e death
(D) m alin gerin g (E) Feelin gs o h op elessn ess
(E) dep ression
29
30 BRS Behavioral Science
32
Chapter 3 Aging, Death, and Bereavement 33
8. The answer is D. Ph ysician s o ten eel th at th ey h ave ailed wh en a p atien t dies. Rath er
th an becom in g closer, th is p h ysician m ay becom e em otion ally detach ed rom th e p atien t
in order to deal with h is im p en din g death . Heavy sedation is rarely in dicated as treatm en t
or th e bereaved becau se it m ay in ter ere with th e grievin g p rocess. Gen erally, p h ysician s
in orm p atien ts wh en th ey h ave a term in al illn ess an d p rovide an im p ortan t sou rce o
su p p ort or th e am ily be ore an d a ter th e p atien t’s death .
9. The answer is C. Th e di eren ce in li e exp ectan cy between Wh ite wom en (81.0 years)
an d A rican -Am erican m en (71.4 years) is ap p roxim ately 10 years. Th e di eren ce in li e
exp ectan cy by age an d sex is cu rren tly d ecreasin g.
10. The answer is C. Six m on th s a ter th e d eath o a loved on e, den yin g th at th e death h as
actu ally occu rred su ggests a com p licated grie reaction . Norm ally, d en ial lasts u p to 24
h ou rs. Lon gin g, cryin g, irritability, an d illu sion s are all p art o a n orm al grie reaction .
11. The answer is A. Th is 80-year-old wom an is p robably sh owin g n orm al agin g, sin ce sh e
can u n ction well livin g alon e. Min or m em ory loss th at d oes n ot in ter ere with n orm al
u n ction in g su ch as sh e describes is typ ically seen in n orm ally agin g p eop le. Th ere is n o
evid en ce th at th is p atien t h as Alzh eim er’s d isease, d ep ression , or an an xiety d isord er.
12. The answer is A. Th e an tih istam in ergic agen t dip h en h ydram in e (Ben adryl) sh ou ld
be avoid ed in elderly p atien ts b ecau se it is likely to cau se sym p tom s o deliriu m .
Un ortu n ately, a n u m b er o over-th e-cou n ter sleep m edicin es su ch as Tylen ol PM con tain
dip h en h yd ram in e. Better ch oices or in som n ia in th e elderly in clu de n ewer sleep agen ts
su ch as zolp id em (Am bien ) an d ram elteon (Rozerem ). Trazodon e is a sedatin g tricyclic
an tid ep ressan t wh ich is also u se u l or occasion al p rob lem s allin g asleep in th e elderly.
13. The answer is A. It is u p to th e m oth er to d ecid e wh eth er, wh en , an d h ow to tell h er son
abou t h er illn ess. However, sch ool-age ch ildren are o ten aware wh en som eth in g seriou s
is goin g on with in th eir am ily an d can u n derstan d th e m ean in g o death (see Ch ap ter 2).
Th ere ore, wh ile it is n ot ap p rop riate or th e p h ysician to in sist th at th e p atien t tell h er son ,
th e p h ysician sh ou ld talk to th e m oth er an d en cou rage h er to talk to h er son abou t h er
term in al con dition . Th e p h ysician can also cou n sel th e p atien t on wh at to say to h er ch ild
abou t h er im m in en t death .
14. The answer is C. Th is p atien t, wh ose wi e died 8 m on th s ago, is sh owin g a n orm al grie
reaction . Alth ou gh h e som etim es wakes u p an h ou r earlier th an u su al an d cries wh en h e
th in ks abou t h is wi e, h e is attem p tin g to retu rn to h is li estyle by rejoin in g h is bowlin g
team an d visitin g with h is am ily. Th e illu sion o believin g h e sees an d th u s ollows a
wom an wh o resem bled h is late wi e is seen in a n orm al grie reaction . For a n orm al grie
reaction , recom m en din g regu lar p h on e calls an d visits to “ch eck in” with th e doctor is
th e ap p rop riate in terven tion . Sleep m ed ication , an tidep ressan ts, p sych oth erapy, an d a
n eu rop sych ological evalu ation are n ot n ecessary or th is p atien t at th is tim e.
15. The answer is B. Th ere is n o in d ication th at th is eld erly wom an is im p aired m en tally or
p h ysically. Th ere ore, th e p h ysician sh ou ld tell h er th e tru th , th at is, th at h er h u sban d h as
died an d th en stay an d o er su p p ort. As with all adu lt p atien ts, eld erly p atien ts sh ou ld b e
told th e tru th . It is n ot n ecessary to wait or th e son to arrive, an d tellin g h er n ot to worry is
p atron izin g.
Gen etics, An atom y,
c ha pte r
4 an d Bioch em istry
o Beh avior
B. Specific chromosomes h ave been associated with oth er disorders with beh avioral sym p tom s
(Table 4.1).
34
Chapter 4 Genetics, Anatomy, and Biochemistry of Behavior 35
B. Th e PNS con tain s all sensory, motor, and autonomic ib ers ou tsid e o th e CNS, in clu d in g th e
spinal nerves, cranial nerves , an d peripheral ganglia .
1. Th e PNS ca rries sensory in orm a tio n to th e CNS a n d motor in orm a tio n awa y rom
th e CNS.
Frontal lobes Mood changes (e.g., depression with dominant lesions, mood elevation with nondominant
lesions)
Difficulties with motivation, concentration, attention, orientation, and problem solving
(dorsolateral convexity lesions)
Difficulties with judgment, inhibitions, emotions, personality changes (orbitofrontal lesions)
Inability to speak fluently (i.e., Broca aphasia [dominant lesions])
Temporal lobes Impaired memory
Psychomotor seizures
Changes in aggressive behavior
Inability to understand language (i.e., Wernicke’s aphasia [dominant lesions])
Limbic lobes Poor new learning; implicated specifically in Alzheimer’s disease
Hippocampus Klüver-Bucy syndrome (decreased aggression, increased sexual behavior, hyperorality)
Amygdala Decreased conditioned fear response
Problems recognizing the meaningfulness of facial and vocal expressions of anger in others
Parietal lobes Impaired processing of visual–spatial information (e.g., cannot copy a simple line drawing or
neglects the numbers on the left side when drawing a clock face [right-sided lesions])
Impaired processing of verbal information (e.g., cannot tell left from right, do simple math, name
fingers, or write [Gerstmann’s syndrome, dominant lesions])
Occipital lobes Visual hallucinations and illusions
Inability to identify camouflaged objects
Blindness
Hypothalamus Hunger leading to obesity (ventromedial nucleus damage), loss of appetite leading to weight loss
(lateral nucleus damage)
Effects on sexual activity and body temperature regulation
Reticular system Changes in sleep–wake mechanisms (e.g., decreased REM sleep)
Loss of consciousness
Basal ganglia Disorders of movement (e.g., Parkinson’s disease [substantia nigra], Huntington’s disease
[caudate and putamen], and Tourette’s syndrome [caudate])
Chapter 4 Genetics, Anatomy, and Biochemistry of Behavior 37
Type of System Type of Memory Associated Anatomy Length of Recall Memory Used to Remember
III. NEUROTRANSMISSION
A. Synapses and neurotransmitters
1. In orm ation in th e n ervou s system is tran s erred across th e synaptic cleft (i.e., th e sp ace
b etween th e axon term in al o th e p resyn ap tic n eu ron an d th e den drite o th e p ostsyn ap -
tic n eu ron ).
2. Wh en th e p resyn ap tic n eu ron is stim u lated, a neurotransmitter is released, travels across
th e syn ap tic cle t, an d acts on recep tors on th e p ostsyn ap tic n eu ron . Neu rotran sm itters
are excitatory i th ey in crease th e ch an ces th at a n eu ron will ire an d inhibitory i th ey
decrease th ese ch an ces.
3. Availability o sp eci ic n eu rotran sm itters is associated with com m on psychiatric con dition s
(Table 4.4). Norm alization o n eu rotran sm itter availability by pharm acological agen ts is
associated with sym p tom im p rovem en t in th ese disorders (see Chap ter 16).
B. Dopamine
1. Dop am in e, a catech olam in e, is in volved in th e p ath op h ysiology o schizophrenia an d other
psychotic disorders, Parkinson’s disease, mood disorders , th e con dition ed ear resp on se
(see Ch ap ter 7), an d th e “rewardin g” n atu re o certain d ru gs (see Ch ap ter 9).
2. Synthesis. Th e am in o acid tyrosin e is con verted to th e p recu rsor or dop am in e by th e
en zym e tyrosine hydroxylase .
3. Receptor subtypes. At least ive d op am in e recep tor su btyp es (D 1–D 5) h ave been iden ti ied;
th e m ajor site o action is D 2 or tradition al an tip sych otic agen ts an d D 1 an d D 4 as well as
D 2 or th e n ewer “atyp ical” an tip sych otic agen ts (see Ch ap ter 16).
Orbitofronta l Ve ntra l
corte x te gme nta l
a re a
S e pta l
nucle i
Nucle us S ubs ta ntia
a ccumbe ns nigra
OH H H Amygda la
HO C C NH2 P ons Ce re be llum
H H
Dopa mine Me dulla
A
Ce rulocortica l
tra ct
Fornix
Locus
ce rule us
Amygda la
Hippoca mpus
OH
OH H
HO C C NH2
H H
Nore pine phrine
B
Ra phe cortica l
tra ct
Fornix
Amygda la
Hippoca mpus
Ra phe nucle i
H H
HO
C C NH2
N H H
S e rotonin
C
FIGURE 4.1. Distribution of (A) dopaminergic, (B) noradrenergic, and (C) serotonergic tracts in the CNS.
40 BRS Behavioral Science
C. Norepinephrine, a catech olam in e, p lays a role in mood, anxiety, arousal, learning, an d memory.
1. Synthesis
a. Like dop am in ergic n eu ron s, n oradren ergic n eu ron s syn th esize dop am in e.
b. Dop am in e β-h yd roxylase, p resen t in n oradren ergic n eu ron s, con verts th is dop am in e
to n orep in ep h rin e.
2. Localization. Most n oradren ergic n eu ron s (ap p roxim ately 10,000 p er h em isp h ere in th e
brain ) are located in th e locus ceruleus (Figure 4.1B).
D. Serotonin, an in dolam in e, p lays a role in mood, sleep, sexuality, an d impulse control. Elevation
o seroton in is associated with im p roved m ood an d sleep but decreased sexu al u n ction (p ar-
ticu larly delayed orgasm ). Very h igh levels are associated with psychotic symptoms (see Ch ap ter
11). Decreased seroton in is associated with poor im pulse con trol, dep ression , an d poor sleep.
1. Synthesis. The am ino acid tryptophan is converted to serotonin (also known as 5-hydroxytrypta-
mine [5-HT]) by the enzym e tryptophan hydroxylase as well as by an am in o acid decarboxylase.
2. Localization. Most seroton ergic cell bodies in th e brain are con tain ed in th e dorsal raphe
nucleus in the upper pons and lower midbrain (Figure 4.1C).
3. Antidepressants and serotonin. Heterocyclic an tidep ressan ts (HCAs ), selective seroton in
an d seroton in an d n orep in ep h rin e reu p take in h ib itors (SSRIs an d SNRIs ), an d m on o-
am in e oxidase in h ibitors (MAOIs ) u ltim ately in crease th e p resen ce o seroton in an d
n orep in ep h rin e in th e syn ap tic cle t (Ch ap ter 16).
a. HCAs an d SNRIs b lock reu p take o seroton in an d n orep in ep h rin e, an d SSRIs su ch as
lu oxetin e (Prozac) selectively block reu p take o seroton in by th e p resyn ap tic n eu ron .
b. MAOIs p reven t th e d egrad ation o seroton in an d n orep in ep h rin e by MAO.
E. Histamine
1. Histam in e, an ethylamine , is a ected by p sych oactive dru gs.
2. Histam in e recep tor b lockade with dru gs su ch as an tip sych otics an d tricyclic an tidep res-
san ts is associated with com m on sid e e ects o th ese d ru gs su ch as sedation an d increased
appetite lead in g to weigh t gain .
A. Glutamate
1. Glu tam ate is an excitatory n eu rotran sm itter th at con tribu tes to th e p ath op h ysiology o
neurodegenerative illnesses su ch as Alzh eim er’s d isease an d sch izop h ren ia.
a. Th e m ech an ism o th is association in volves activation o th e glu tam ate recep tor
N-methyl-d -aspartate (NMDA) by su stain ed elevation o glu tam ate.
b. Su ch activation resu lts in calciu m ion s en terin g n eu ron s leadin g to n erve cell degen -
eration an d d eath th rou gh excitotoxicity.
c. Memantine (Nam en d a), an NMDA recep tor an tagon ist, u ltim ately blocks this influx of
calcium an d is in dicated or p atien ts with m oderate to severe Alzheimer’s d isease.
B. GABA
1. GABA is th e p rin cip al inhibitory n eu rotran sm itter in th e CNS. It is syn th esized rom glu ta-
m ate by th e en zym e glu tam ic acid d ecarboxylase, wh ich n eed s vitam in B6 (pyrid oxin e) as
a co actor.
2. GABA is closely in volved in th e action o an tian xiety agen ts su ch as benzodiazepines (e.g.,
d iazep am [Valiu m ]) an d barbiturates (e.g., secobarb ital [Secon al]). Ben zodiazep in es an d
b arb itu rates in crease th e a in ity o GABA or its GABAA-binding site , allowin g m ore ch lo-
rid e to en ter th e n eu ron . Th e ch lorid e-laden n eu ron s b ecom e h yp erp olarized an d in h ib-
ited , d ecreasin g n eu ron al irin g an d u ltim ately decreasin g an xiety. An ticon vu lsan ts also
p oten tiate th e activity o GABA.
VI. NEUROPEPTIDES
A. Endogenous opioids such as enkephalins, endorphins, dynorphins, and endomorphins are p ro-
d u ced by th e b rain itsel . Th ey act to d ecrease p ain an d an xiety an d h ave a role in addiction
an d m ood.
B. Placebo effects (see Ch ap ter 25) m ay b e m ediated by th e en d ogen ou s op ioid system . For
exam p le, p rior treatm en t with an op ioid recep tor blocker su ch as n aloxon e can b lock p la-
ceb o e ects.
Review Test
42
Chapter 4 Genetics, Anatomy, and Biochemistry of Behavior 43
8. Th e m ajor n eu rotran sm itter im p licated in 13. A 55-year-old wom an was diagn osed
both Alzh eim er’s disease an d sch izop h ren ia is with sch izop h ren ia at th e age o 22. I th is
(A) seroton in diagn osis was ap p rop riate, th e volu m e o
(B) n orep in ep h rin e th e h ip p ocam p u s, th e size o th e cereb ral
(C) dop am in e ven tricles, an d glu cose u tilization in th e
(D) γ-am in obu tyric acid (GABA) ron tal cortex o th is p atien t are n ow m ost
(E) acetylch olin e (Ach ) likely to b e, resp ectively
(F) glu tam ate (A) in creased, in creased, in creased
(B) decreased , decreased , d ecreased
9. Th e m ajor n eu rotran sm itter in volved (C) decreased , decreased , in creased
in th e an tidep ressan t action o u oxetin e (D) decreased , in creased , decreased
(Prozac) is (E) in creased, decreased, in creased
(A) seroton in
(B) n orep in ep h rin e 14. An 80-year-old em ale p atien t h as
(C) dop am in e a restin g trem or o h er le t h an d, little
(D) γ-am in obu tyric acid (GABA) exp ression in h er ace, an d p roblem s takin g
(E) acetylch olin e (Ach ) a f rst step wh en sh e h as been stan din g still.
(F) glu tam ate Th e area(s) o th e brain m ost likely to b e
a ected in th is p atien t is (are) th e
10. Th e n eu rotran sm itter m etabolized to (A) righ t p arietal lob e
5-HIAA (5-h yd roxyin doleacetic acid) is (B) basal gan glia
(A) seroton in (C) h ip p ocam p u s
(B) n orep in ep h rin e (D) reticu lar system
(C) dop am in e (E) am ygd ala
(D) γ-am in obu tyric acid (GABA) (F) le t ron tal lobe
(E) acetylch olin e (Ach )
(F) glu tam ate Questions 15 and 16
11. A 25-year-old m ale p atien t su stain s A 69-year-old orm er ban k p residen t can n ot
a seriou s h ead in ju ry in an au tom obile tell you th e n am e o th e cu rren t p resid en t
acciden t. He h ad b een aggressive an d an d h as d i icu lty id en ti yin g th e wom an sit-
assau ltive, b u t a ter th e accid en t, h e is tin g n ext to h im (h is wi e). He b egan h avin g
p lacid an d coop erative. He also m akes m em ory p roblem s 3 years ago.
in ap p rop riate su ggestive com m en ts to th e
n u rses an d m astu rb ates a great d eal. Th e 15. Atrop h y o wh ich area(s) o th e brain is
area(s) o th e brain m ost likely to be in ju red (are) m ost likely to be seen in th is p atien t?
in th is p atien t is (are) th e (A) righ t p arietal lob e
(A) righ t p arietal lob e (B) basal gan glia
(B) basal gan glia (C) h ip p ocam p u s
(C) h ip p ocam p u s (D) reticu lar system
(D) reticu lar system (E) am ygd ala
(E) am ygd ala (F) le t ron tal lobe
(F) le t ron tal lobe
16. Th e p ostm ortem brain biop sy o th is
12. A 35-year-old em ale p atien t rep orts p atien t is m ost likely to sh ow
th at sh e h as d i f cu lty sleep in g ever sin ce (A) in creased 3-m eth oxy-4-
sh e su stain ed a con cu ssion in a su bway h ydroxyp h en ylglycol (MHPG)
acciden t. Th e area(s) o th e brain m ost likely (B) righ t ron tal h yp ertrop h y
to be a ected in th is p atien t is (are) th e (C) decreased calciu m levels
(A) righ t p arietal lob e (D) decreased h om ovan illic acid (HVA)
(B) basal gan glia (E) dep osition o β-am yloid
(C) h ip p ocam p u s
(D) reticu lar system
(E) am ygd ala
(F) le t ron tal lobe
44 BRS Behavioral Science
25. A 72-year-old m an with Alzh eim er’s 27. Th e brain p ath way m ost closely
d isease is b ein g treated with m em an tin e. associated with th e disp lay o n egative
Wh at is believed to be th e basis o th e sym p tom s in sch izop h ren ia is th e
th erap eu tic action o m em an tin e on n eu ron s (A) m esocortical tract
in th e b rain ? (B) m esolim b ic tract
(A) To in h ibit th e action o (C) tu beroin u n dibu lar tract
acetylch olin esterase (D) ceru locortical tract
(B) To block th e in lu x o calciu m (E) rap h e cortical tract
(C) To in h ibit th e action o acetylch olin e
(D) To in crease th e in lu x o glu tam ate
(E) To acilitate th e in lu x o calciu m
An swers an d Exp lan ation s
1. The answer is F. O th e listed brain areas, d ep ression is m ost likely to b e associated with
d am age to th e le t ron tal lobe.
2. The answer is D. A 24-h ou r u rin e stu dy is m ost likely to reveal elevated levels o VMA, a
m etab olite o n orep in ep h rin e. An xiety, ab dom in al cram p s an d d iarrh ea, an d skin lu sh in g
are sym p tom s o p h eoch rom ocytom a, a n orep in ep h rin e-secretin g adren al tu m or. Th is
p ictu re is n ot seen with elevated levels o oth er n eu rotran sm itter m etabolites.
3. The answer is C. Sin ce th e p lacebo respon se is based in part on activation o the
en dogen ou s op ioid system , it will be blocked by n aloxon e, an d this p atien t’s pain will be
u n ch an ged. Th is exp erim en t will n ot n ecessarily a ect her respon se to opioids in the uture.
4. The answer is D. Dom in an ce or lan gu age in both righ t-h an ded an d le t-h an ded p eop le is
u su ally in th e le t h em isp h ere o th e brain . Percep tion , m u sical ability, artistic ability, an d
sp atial relation s p rim arily are u n ction s o th e righ t sid e o th e brain .
5. The answer is D. Th e corp u s callosu m an d th e h ip p ocam p al, h aben u lar, an d an terior
com m issu res con n ect th e two h em isp h eres o th e b rain . Th e basal gan glia, reticu lar
system , an d am ygd ala do n ot h ave th is u n ction .
6. The answer is D. Sedation , in creased appetite, an d weight gain are side e ects o treatm en t
with certain an tipsychotic agen ts. The m echan ism m ost closely associated with these side
e ects is blockade o histam in e receptors sin ce these an tipsychotics are n ot speci ic or
dopam in e blockade. Blockade o dopam in e receptors by these antipsychotic m edications is
associated with side e ects such as parkin son ism -like sym ptom s and elevated prolactin levels.
7. The answer is E. Th is 3-year-old girl is sh owin g sign s o Rett’s disorder th at is lin ked to th e X
ch rom osom e. Rett’s d isord er is ch aracterized by loss o social skills a ter a p eriod o typ ical
un ction in g as well as h an d-wrin gin g an d breath in g abn orm alities (see also Ch ap ter 15).
8. The answer is F. Wh ile acetylch olin e (Ach ) is th e m ajor n eu rotran sm itter im p licated in
Alzh eim er’s disease, abn orm alities in glu tam ate are seen in both Alzh eim er’s disease an d
sch izop h ren ia.
9. The answer is A. Blockade o seroton in reu p take by p resyn ap tic n eu ron s is th e p rim ary
action o th e an tidep ressan t lu oxetin e.
10. The answer is A. Seroton in is m etabolized to 5-HIAA.
11. The answer is E. Th e p atien t is sh owin g evid en ce o th e Klü ver-Bu cy syn drom e, wh ich
in clu d es h yp ersexu ality an d docility an d is associated with dam age to th e am ygdala.
12. The answer is D. Sleep –arou sal m ech an ism s are a ected by dam age to th e reticu lar
system .
13. The answer is D. Alth ou gh n eu roim agin g can n ot be u sed to diagn ose p sych iatric disorders,
brain s o p atien ts with sch izop h ren ia su ch as th is wom an are likely to sh ow d ecreased
volu m e o lim b ic stru ctu res su ch as th e h ip p ocam p u s; in creased size o cerebral ven tricles
du e, in p art, to b rain sh rin kage; an d decreased glu cose u tilization in th e ron tal cortex.
46
Chapter 4 Genetics, Anatomy, and Biochemistry of Behavior 47
14. The answer is B. Th is 80-year-old em ale p atien t is sh owin g sign s o Parkin son’s disease
(e.g., a restin g trem or, little acial exp ression , an d p roblem s in itiatin g m ovem en t). Th is
disord er is associated with ab n orm alities o th e b asal gan glia.
15. The answers is C. 16. The answer is E. This patien t is sh owin g eviden ce o Alzh eim er’s
disease. O th e listed brain areas, th e m ajor on e im p licated in Alzheim er’s disease is th e
h ip p ocam p u s. Am yloid p laqu es are seen on brain biop sy o Alzheim er’s disease p atien ts.
17. The answer is D. Assau ltive, im p u lsive, aggressive beh avior like th at seen in th is
28-year-old m ale p atien t is associated with decreased levels o seroton in in th e
brain . Levels o 5-HIAA (5-h yd roxyin d oleacetic acid), th e m ajor m etabolite o
seroton in , h ave been sh own to b e decreased in th e body lu ids o violen t, aggressive,
im p u lsive in dividu als as well as dep ressed in dividu als. MHPG (3-m eth oxy-4-
h ydroxyp h en ylglycol), a m etab olite o n orep in ep h rin e, is decreased in severe
dep ression , wh ile h om ovan illic acid (HVA), a m etabolite o d op am in e, is d ecreased in
Parkin son’s disease an d d ep ression .
18. The answer is C. Th e e ectiven ess o clon idin e in treatin g with drawal sym p tom s
associated with th e u se o op ioids an d sedatives is believed to be du e to its action on
alp h a 2-ad ren ergic recep tors, or exam p le, red u cin g th e irin g rate o n orad ren ergic
n eu ron s, m ost o wh ich are located in th e locu s ceru leu s.
19. The answer is B. g-Am in ob u tyric acid (GABA) is an in h ibitory am in o acid
n eu rotran sm itter in th e CNS. Th u s, th e activity o GABA in th e brain o th is an xiou s
p atien t is likely to be decreased. Decreased seroton in an d in creased dop am in e are also
in volved in an xiety (Table 4.4).
20. The answer is C. Beh avioral ch an ges su ch as decreased im p u lse con trol, p oor social
beh avior, an d lack o ch aracteristic m odesty in d icate th at th e area o th e b rain m ost
likely to h ave b een in ju red in th is p atien t is th e orbito ron tal cortex. Lesion s o th is
brain area resu lt in d isin h ib ition , in ap p rop riate beh avior, an d p oor ju d gm en t. In
con trast, lesion s o th e dorsolateral con vexity o th e ron tal lobe resu lt in decreased
execu tive u n ction in g (e.g., m otivation , con cen tration , an d atten tion ). Th e
h yp oth alam u s is associated with h om eostatic m ech an ism s an d th e reticu lar system
with con sciou sn ess an d sleep. Dam age to th e am ygdala resu lts in decreased, n ot
in creased, aggression . Th e n u cleu s basalis o Meyn ert is a site o Ach p rodu ction ; its
dam age cou ld resu lt in d e icits in in tellectu al u n ction in g.
21. The answer is E. In creased body lu id level o hom ovan illic acid (HVA), a m ajor
m etabolite o dopam in e, is seen in sch izoph ren ia. Decreased HVA is seen in Parkin son’s
disease, depression , an d in m edicated schizophren ic patien ts. In creased van illylm an delic
acid (VMA), a m etabolite o n orep in ep h rin e, is seen in p heoch rom ocytom a. Decreased
body luid level o 5-HIAA, a m etabolite o seroton in , is seen in depression an d in bulim ia
(Table 4.5).
22. The answer is A. Rem em berin g th at sch ool closes early be ore Th an ksgivin g Day every
year is an exam p le o sem an tic m em ory. Sem an tic m em ory is a typ e o declarative
m em ory th at in volves rem em berin g gen eral kn owledge abou t th e world. Ep isodic
m em ory in volves rem em berin g p erson ally exp erien ced even ts, p rocedu ral m em ory
in volves rem em berin g th in gs on e does au tom atically, an d workin g m em ory in volves
rem em berin g recen t in orm ation .
23. The answer is B. Decreased availability o acetylch olin e by blockade o m u scarin ic
acetylch olin e recep tors (i.e., an tich olin ergic activity) in th e CNS is associated with
m em ory p rob lem s. Blockade o ad ren ergic, d op am in ergic, h istam in ergic, an d
seroton ergic recep tors are less likely to b e associated with m em ory p rob lem s.
24. The answer is B. Ch rom osom e 16 an d ch rom osom e 9 are b oth associated with
tu berou s sclerosis. Seizu res, cogn itive de ects, au tistic beh avior, an d oreh ead p laqu es
in th is 6-year-old ch ild are seen in th is disorder.
48 BRS Behavioral Science
25. The answer is B. Th e th erap eu tic action o m em an tin e in Alzh eim er’s d isease is b elieved to
be to d ecrease th e in lu x o glu tam ate, u ltim ately b lockin g th e in lu x o calciu m , wh ich can
lead to n erve cell degen eration an d d eath . In con trast to a grou p o dru gs also u sed to treat
Alzh eim er’s, th at is, th e acetylch olin esterase in h ib itors, m em an tin e d oes n ot directly a ect
acetylch olin e.
26. The answer is E. Th e am ygdala is an im p ortan t b rain area or th e evalu ation o sen sory
stim u li with em otion al sign i ican ce. Th u s, th e brain area m ost likely to be activated by
th ese p h otos is th e am ygdala.
27. The answer is A. Dop am in e h yp oactivity in th e m esocortical tract is associated with th e
n egative sym p tom s o sch izop h ren ia (an d see Ch ap ter 11). Dop am in e h yp eractivity in th e
m esolim b ic tract is associated with th e p ositive sym p tom s o sch izop h ren ia. Dop am in e
acts on th e tu beroin u n d ibu lar tract to in h ibit th e secretion o p rolactin rom th e an terior
p itu itary. Th e cerulocortical tract is associated with th e action o n orep in ep h rin e, wh ile th e
rap h e cortical tract is associated with th e action o seroton in .
Biological Assessm en t o
c ha pte r
5 Patien ts with Psych iatric
Sym p tom s
I. OVERVIEW
Biological alteration s an d ab n orm alities can u n derlie p sych iatric sym p tom s an d in lu en ce th eir
occu rren ce. A variety o laboratory stu d ies are u sed clin ically to iden ti y su ch alteration s an d
abn orm alities in p atien ts.
A. Altered levels o b iogen ic am in es an d th eir m etabolites occu r in som e p sych iatric con dition s
(see Tab les 4.2 an d 4.3).
B. Plasm a levels o som e an tip sych otic an d an tidep ressan t agen ts are m easu red to evalu ate
patient compliance or to determ in e wh eth er therapeutic blood levels o th e agen t h ave been
reach ed.
C. Laboratory tests also are used to monitor patients for complications of pharmacotherapy.
1. Patien ts takin g certain m ood stabilizers, or exam p le, carbam azep in e (Tegretol), or an ti-
p sych otics, or exam p le, clozap in e (Clozaril), m u st be observed or blood abn orm alities
su ch as agranulocytosis (very low, e.g., <2,000, wh ite blood cell cou n t or gran u locyte cou n t
<1,000).
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2. Liver function tests are u sed in p atien ts b ein g treated with carbam azep in e an d valp roic
acid (m ood stabilizers).
3. Thyroid function an d kidney function tests sh ou ld be u sed in p atien ts wh o are bein g treated
with th e m ood stab ilizer lithium. Patien ts takin g lith iu m can develop hypothyroidism an d,
occasion ally, h yp erth yroid ism .
4. Lith iu m levels sh ou ld also be m on itored regu larly becau se o th e dru g’s narrow therapeu-
tic range (see Ch ap ter 16).
B. Thyroid u n ction tests are u sed to screen or hypothyroidism an d hyperthyroidism, wh ich can
m im ic d ep ression an d an xiety, resp ectively.
1. Ph ysical sym p tom s o h yp oth yroidism in clu de atigu e, weigh t gain , edem a, h air loss, an d
cold in toleran ce.
2. Ph ysical sym p tom s o h yp erth yroidism in clu de rap id h eartbeat (“p alp itation s”), lu sh in g,
ever, weigh t loss, an d diarrh ea.
C. Patien ts with d ep ression m ay h ave oth er endocrine irregularities , su ch as redu ced resp on se
to a ch allen ge with th yrotrop in -releasin g h orm on e, an d abn orm alities in growth h orm on e,
m elaton in , an d gon ad otrop in .
D. Psych iatric sym p tom s are associated with oth er en docrin e disorders, su ch as Addison’s dis-
ease (hypocortisolism), Cushing’s disease (hypercortisolism), an d en zym e d isord ers su ch as
acute intermittent porphyria.
1. Addison’s disease
a. Ph ysical sign s an d sym p tom s in clu de hyperpigmentation of the skin, p articu larly in skin
creases, low b lood p ressu re, p ain , ain tin g, h yp oglycem ia, diarrh ea, an d vom itin g.
b. Psych iatric sym p tom s in clu de atigu e, d ep ression , p sych osis, an d con u sion .
2. Cushing’s disease
a. Ph ysical sign s an d sym p tom s in clu de rou n d “moon” face , bru isin g, p u rp le striae on th e
skin , sweatin g, acial h air, h yp erten sion , at on th e back o th e n eck (“bu alo h u m p”),
an d a p ositive DST.
b. Psych iatric sym p tom s in clu de elevated m ood, p sych osis, an xiety, an d dep ression .
3. Acute intermittent porphyria
a. Ph ysical sign s an d sym p tom s in clu d e abd om in al cram p s, diarrh ea an d vom itin g, sei-
zu res, cardiac arrh yth m ias, lu sh in g, an d purple/red discoloration of the urine du e to
elevated porphobilinogen.
b. Psych iatric sym p tom s in clu de p aran oid delusions an d h allu cin ation s as well as dep res-
sion an d an xiety.
Computed tomography (CT) Identifies anatomically based brain changes (e.g., enlarged brain
ventricles) seen in cognitive disorders, such as Alzheimer’s disease, as
well as in schizophrenia
Nuclear magnetic resonance imaging Identifies demyelinating disease (e.g., multiple sclerosis)
(NMRI) Shows the biochemical condition of neural tissues without exposing the
patient to ionizing radiation
Positron emission tomography (PET) or Localizes areas of the brain that are physiologically active during specific
functional MRI (fMRI) tasks by characterizing and measuring metabolism of glucose in neural
tissue
Measures specific neurotransmitter receptors
Requires use of a cyclotron
Single photon emission tomography (SPECT) Obtains similar data to PET or fMRI but is more practical for clinical use
because it uses a standard gamma camera rather than a cyclotron
Electroencephalogram (EEG) Measures electrical activity in the cortex
Is useful in diagnosing epilepsy and in differentiating delirium (often
abnormal EEG) from dementia (often normal EEG)
Shows, in patients with schizophrenia, decreased alpha waves, increased
theta and delta waves, and epileptiform activity
Evoked EEG (evoked potentials) Measures electrical activity in the cortex in response to tactile, auditory, or
visual stimulation
Is used to evaluate vision and hearing loss in infants and brain responses
in comatose and suspected brain-dead patients
V. NEUROPSYCHOLOGICAL TESTS
A. Neu rop sych ological tests are d esign ed to assess gen eral in telligen ce, m em ory, reason in g,
orien tation , p ercep tu om otor p er orm an ce, lan gu age u n ction , atten tion , an d con cen tra-
tion in p atien ts with su sp ected n eu rologic p roblem s, su ch as dem en tia an d brain dam age
(Tab le 5.2).
B. In su ch p atien ts, th e Folstein Mini–Mental State Examination (Tab le 5.3) is d esign ed to ol-
low th e im p rovem en t or d eterioration in cogn itive u n ction , an d th e Glasgow Coma Scale
(Tab le 5.4) is d esign ed to assess th e level o con sciou sn ess by ratin g p atien t resp on siven ess.
B. Sodium lactate administration. In traven ou s (IV) adm in istration o sodiu m lactate can provoke
panic attacks (see Chapter 13) in susceptible patients an d can th u s h elp to iden ti y in d ivid u als
with p an ic d isorder. In h alation o carb on dioxid e can p rod u ce th e sam e e ect.
Number of Points Best Eye-Opening Response (E) Best Verbal Response (V) Best Motor Response (M)
8. To di eren tiate deliriu m rom dem en tia 11. A 55-year-old m ale p atien t with n o
in a 75-year-old m ale p atien t, th e m ost h istory o p sych iatric illn ess is adm itted
ap p rop riate diagn ostic tech n iqu e is to th e h osp ital com p lain in g o in ten se
(A) PET abdom in al p ain . He states th at over th e p ast
(B) CT ew days h is wi e h as been givin g h im ood
(C) am obarb ital sodiu m in terview th at is p oison ed so th at sh e can kill h im an d
(D) EEG b e with an oth er m an . Th e wi e states th at
(E) evoked EEG sh e loves h er h u sban d an d wou ld n ever
(F) Glasgow Com a Scale h arm h im or leave h im . Wh en th e p atien t’s
(G) Folstein Min i–Men tal State Exam in ation u rin e is collected , it ap p ears p u rp lish red in
color. Urin e testin g is m ost likely to reveal an
9. A 40-year-old wom an rep orts th at elevated level o
over th e p ast 6 m on th s sh e h as h ad little (A) glu cose
ap petite, sleep s p oorly, an d h as lost in terest (B) 5-h ydroxyin doleacetic acid (5-HIAA)
in her n orm al activities. Ph ysical exam is (C) p orp h obilin ogen
un rem arkab le. Wh ich o th e ollowin g is th e (D) cortisol
m ost likely laboratory n din g in th is wom an ? (E) van illylm an delic acid (VMA)
(A) Positive d exam eth ason e su p p ression test
(DST) 12. Fou r weeks a ter h e begin s to take a n ew
(B) Norm al growth h orm on e regu lation m edication , a 28-year-old m ale p sych iatric
(C) In creased 5-h yd roxyin doleacetic acid p atien t develop s ever an d sore th roat. He
(5-HIAA) levels rep orts eelin g tired, an d blood stu dies reveal
(D) Norm al m elaton in levels a wh ite blood cell (WBC) cou n t o less th an
(E) Hyp erth yroidism 2,000. Th is p atien t is m ost likely to b e takin g
wh ich o th e ollowin g agen ts?
10. A 50-year-old wom an with ou t a p reviou s (A) Am obarbital sodiu m
p sych iatric h istory rep orts th at over th e p ast (B) Clozap in e
ew m on th s sh e h as b egu n to exp erien ce (C) Lith iu m
in ten se an xiety an d h as lost 15 p ou n ds. Th e (D) Dexam eth ason e
p atien t also com p lain s o “f u sh in g an d (E) Sodiu m lactate
p alp itation s.” Wh ich o th e ollowin g is th e
m ost likely lab oratory n din g in th is wom an ?
(A) Positive DST
(B) Norm al growth h orm on e regu lation
(C) In creased 5-HIAA levels
(D) Norm al m elaton in levels
(E) Hyp erth yroidism
An swers an d Exp lan ation s
1. The answer is A. Th e Ben d er Visu al Motor Gestalt Test is u sed to evalu ate visu al an d
m otor ab ility by rep rod u ction o d esign s. Th e Lu ria-Neb raska n eu rop sych ological
b attery is u sed to d eterm in e cereb ral d om in an ce an d to id en ti y sp eci ic typ es o b rain
d ys u n ction , wh ile th e Halstead -Reitan b attery is u sed to d etect an d localize b rain lesion s
an d d eterm in e th eir e ects. Th e d exam eth ason e su p p ression test is u sed to p red ict
wh ich d ep ressed p atien ts will resp on d well to treatm en t with an tid ep ressan t agen ts or
electrocon vu lsive th erapy. Th e electroen cep h alogram (EEG), wh ich m easu res electrical
activity in th e cortex, is u se u l in d iagn osin g ep ilep sy an d in d i eren tiatin g d eliriu m rom
d em en tia.
2. The answer is A. Th is em ale p atien t is sh owin g eviden ce o h yp ocortisolism or Addison’s
d isease. Th is con dition is ch aracterized by darken in g o th e skin , p articu larly in p laces n ot
exp osed to th e su n su ch as skin creases an d in side th e m ou th . Th is darken in g is n ot seen
in h yp ercortisolism , p h eoch rom ocytom a, or h yp er- or h yp oth yroidism . Hyp ercortisolism ,
wh ich also m ay lead to dep ression an d an xiety, is ch aracterized by weigh t gain , “m oon -”
sh ap ed ace, an d skin striae. Dep ression , dry h air, an d weigh t gain ch aracterize
h yp oth yroid ism , wh ile an xiety, ever, weigh t loss, an d elevated h eart rate ch aracterize
h yp erth yroid ism . Patien ts with p h eoch rom ocytom a sh ow in ten se an xiety an d elevated VMA
in body lu ids (see Ch ap ter 4).
3. The answer is D. In traven ou s adm in istration o sodiu m lactate can h elp iden ti y in dividu als
with p an ic disorder sin ce it can p rovoke a p an ic attack in su ch p atien ts.
4. The answer is A. Positron em ission tom ograp h y (PET) localizes p h ysiologically active
b rain areas by m easu rin g glu cose m etab olism . Th u s, th is test can be u sed to determ in e
wh ich brain area is bein g u sed du rin g a sp eci ic task (e.g., tran slatin g a p assage written in
Sp an ish ).
5. The answer is E. Th e au ditory evoked EEG can be u sed to assess wh eth er th is ch ild can h ear.
Evoked EEGs m easu re electrical activity in th e cortex in resp on se to sen sory stim u lation .
6. The answer is C. Th e am ob arb ital sod iu m (Am ytal) in terview is u sed to determ in e
wh eth er p sych ological actors are resp on sible or sym p tom s in th is p atien t wh o sh ows a
n on m ed ically exp lain ed loss o sen sory u n ction (con version disorder—see Ch ap ter 14).
7. The answer is B. Com p u ted tom ograp h y (CT) id en ti ies an atom ical b rain ch an ges, su ch
as en larged ven tricles. Th u s, alth ou gh n ot d iagn ostic, th is test can be u sed to id en ti y
an atom ical ch an ges in th e b rain , su ch as en larged ven tricles in a p atien t with su sp ected
Alzh eim er’s d isease.
8. The answer is D. Electroen cep h alogram (EEG) m easu res electrical activity in th e cortex an d
can b e u se u l in di eren tiatin g deliriu m (ab n orm al EEG) rom d em en tia (u su ally n orm al
EEG).
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56 BRS Behavioral Science
I. OVERVIEW
Psych oan alytic th eory is b ased on Freu d’s con cep t th at beh avior is determ in ed by orces derived
rom u n con sciou s m en tal p rocesses. Psych oan alysis an d related th erap ies are p sych oth erap eu -
tic treatm en ts based on th is con cep t (see Ch ap ter 17).
A. Topographic theory of the mind. In th e top ograp h ic th eory, th e m in d con tain s th ree levels:
Th e u n con sciou s, p recon sciou s, an d con sciou s.
1. Th e unconscious mind con tain s rep ressed th ou gh ts an d eelin gs th at are n ot available to
th e con sciou s m in d, an d u ses p rim ary p rocess th in kin g.
a. Primary process is a typ e o th in kin g associated with p rim itive drives, wish u l illm en t,
an d p leasu re seekin g an d h as n o logic or con cep t o tim e. Prim ary p rocess th in kin g is
seen in you n g ch ildren an d p sych otic adu lts.
b. Dreams rep resen t grati ication o u n con sciou s in stin ctive im p u lses an d wish
u l illm en t.
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2. Th e preconscious mind con tain s m em ories th at, wh ile n ot im m ediately available, can be
accessed easily.
3. Th e conscious mind con tain s th ou gh ts th at a p erson is cu rren tly aware o . It op erates in
close con ju n ction with th e p recon sciou s m in d b u t does n ot h ave access to th e u n con -
sciou s m in d . Th e con sciou s m in d u ses secon d ary p rocess th in kin g (logical, m atu re, tim e
orien ted) an d can delay grati ication .
B. Structural theory of the mind. In th e stru ctu ral th eory, th e m in d con tain s th ree p arts: th e id ,
th e ego, an d th e su p erego (Tab le 6.1).
Acting out Avoiding personally unacceptable A depressed 14-year-old girl with no history
emotions by behaving in an of conduct disorder has sexual encounters
attention-getting, often socially with multiple partners after her parents’
inappropriate manner divorce
Altruisma Assisting others to avoid negative A man with a poor self-image, who is a social
personal feelings worker during the week, donates every
other weekend to charity work
Denial Not accepting aspects of reality that A man who has a problem with alcohol insists
the person finds unbearable that he is only a social drinker
Displacement Moving emotions from a personally A surgeon with unacknowledged anger
intolerable situation to one that is toward his sister is abrasive to the female
personally tolerable residents on his service
Dissociation Mentally separating part of one’s Although he was not injured, a teenager has
consciousness from real-life no memory of a car accident in which he
events or mentally distancing was driving and his girlfriend was killed
oneself from others
Humora Expressing personally uncomfortable A man who is concerned about his erectile
feelings without causing problems makes jokes about Viagra
emotional discomfort (sildenafil citrate)
Idealization Seeing others as more competent or A patient tells the doctor that he is not worried
powerful than they are because he is sure that the doctor will
always know what to do
Identification Unconsciously patterning one’s A man who was terrorized by his gym teacher
(introjection) behavior after that of someone as a child becomes a punitive, critical gym
more powerful (can be either teacher (identification with the aggressor)
positive or negative)
Intellectualization Using the mind’s higher functions to A sailor whose boat is about to sink calmly
avoid experiencing emotion explains the technical aspects of the hull
damage in great detail to the other crew
members
Isolation of affect Failing to experience the feelings Without showing any emotion, a woman tells
associated with a stressful her family the results of tests that indicate
life event, although logically her lung cancer has metastasized
understanding the significance of
the event
Projection Attributing one’s own personally A man with unconscious homosexual impulses
unacceptable feelings to others begins to believe that a male colleague is
Associated with paranoid symptoms attracted to him
and prejudice
Rationalization Distorting one’s perception of an A man who loses an arm in an accident says
event so that its negative outcome the loss of his arm was good because it
seems reasonable kept him from getting in trouble with the
law
Reaction formation Adopting opposite attitudes to A woman who unconsciously is resentful
avoid personally unacceptable of the responsibilities of child rearing
emotions, i.e., unconscious overspends on expensive gifts and clothing
hypocrisy for her children
Regression Reverting to behavior patterns like A woman insists that her husband stay
those seen in someone of a overnight in the hospital with her before
younger age surgery
Splitting Categorizing people or situations into A patient tells the doctor that while all of
categories of either “fabulous” or the doctors in the group practice are
“dreadful” because of intolerance wonderful, all of the nurses and office help
of ambiguity are unfriendly and curt
Seen in patients with borderline
personality disorder
(continued)
60 BRS Behavioral Science
Adapted from Fadem B. Behavioral Science in Medicine. 2nd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2012:83.
B. Transference
1. In positive transference , th e p atien t h as con id en ce in th e d octor. I in ten se, th e p atien t
m ay overid ealize th e d octor or develop sexu al eelin gs toward th e doctor.
2. In negative transference , th e p atien t m ay b ecom e resen t u l or an gry toward th e d octor i
th e p atien t’s desires an d exp ectation s are n ot realized. Th is m ay lead to p oor adh eren ce
to m edical advice.
9. A 15-year-old steals rom am ily m em b ers 13. A 32-year-old m an wh o is u n con sciou sly
an d rien d s. Wh en n o on e is watch in g, h e attracted to h is wi e’s sister becom es
also tortu res th e am ily cat. Wh ich asp ect o extrem ely jealou s wh en ever h is wi e sp eaks
th e m in d is de cien t in th is teen ager? to an oth er m an .
(A) Th e u n con sciou s m in d
(B) Th e p recon sciou s m in d 14. A 45-year-old m an wh o is u n con sciou sly
(C) Th e con sciou s m in d a raid o f yin g rep eatedly states h is love o
(D) Th e su p erego airplan es.
(E) Th e ego
15. A 52-year-old m an receives a letter
rom his physician in orm ing him that his
Questions 10–20 level o prostate-speci c antigen (PSA) was
abnorm ally high during his last visit. When
For th e in d ivid u al in each o th e n u m b ered the m an appears at his physician’s o ce or a
qu estion s, ch oose th e d e en se m ech an ism ollow-up visit, he com plains about a headache
th at h e or sh e is m ost likely to b e u sin g. but does not m ention or seem to rem em ber
An swers can b e u sed m ore th an on ce. receiving the letter about his PSA test.
(A) Regression
(B) Un doin g 16. A 34-year-old wom an relates th at sh e
(C) Den ial wakes u p u lly d ressed at least twice a week
(D) Ration alization b u t th en is tired all day. Sh e also n otes th at
(E) Projection sh e requ en tly receives p h on e calls rom
(F) Dissociation m en wh o say th ey m et h er in a bar bu t wh om
(G) Reaction orm ation sh e does n ot rem em ber m eetin g.
(H) In tellectu alization
(I) Su blim ation 17. A 35-year-old lawyer sch edu led or
(J ) Disp lacem en t su rgery th e n ext day in sists th at h er m oth er
(K) Su p p ression stay overn igh t in th e h osp ital with h er.
(L) Sp littin g
10. A 28-year-old m ed ical resid en t is 18. A wom an , wh ose p aren ts an d teach ers
assign ed to tell a p atien t th at h er illn ess is com p lain ed abou t h ow m essy sh e was as a
term in al. Prior to seein g th e p atien t, th e ch ild, grows u p to becom e a am ou s abstract
residen t con du cts exten sive library research p ain ter. Her tech n iqu e in volves th rowin g
on th e details an d statistics o len gth o p ain t an d sm all ob jects at large can vases an d
su rvival o p eop le with th is illn ess. Wh en h e th en u sin g h er n gers to m ix th e colors an d
sp eaks to th e p atien t, h e cites th e jou rn al textu res.
articles th at h e h as read, in clu din g a detailed
exp lan ation o th e th eories o th e etiology 19. A m an wh o h as ju st received word th at
o her con dition . Later th at day, th e residen t h is ch ild h as been in an acciden t an d h as
tells th e atten d in g p h ysician th at th e p atien t b een taken to th e h osp ital calm ly arran ges
did n ot seem to u n d erstan d wh at h e told h er. or h is work to b e don e by a colleagu e b e ore
h e ru sh es to th e h osp ital.
11. A 40-year-old m an wh o is an gry at h is ill
wi e, bu t does n ot con sciou sly ackn owled ge 20. A 30-year-old wom an wh o was abu sed
th at an ger, sh ou ts at h is ch ild ren as soon as by her ath er th rou gh ou t h er ch ildh ood
h e retu rn s h om e rom work. m an ages h er h ostility toward h im by bakin g
cookies or h im .
12. A 26-year-old m ed ical stu den t wh o h as
u n con sciou s an gry, violen t eelin gs ch ooses 21. A p atien t wh o h as been d iagn osed with
to do a su rgery residen cy. obsessive–com p u lsive disorder tells th e
d octor th at h e h as to cou n t all th e ligh ts in
th e ceilin g b e ore h e can sit down to stu dy.
I h e d oes n ot cou n t th e ligh ts, h e becom es
an xiou s an d is u n able to stu dy.
An swers an d Exp lan ation s
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8. The answer is B. Mem ory o th e details o th e Krebs cycle, wh ile n o lon ger in th e
ore ron t o th e m ed ical stu d en t’s m in d , can be recalled relatively easily 1 week a ter th e
exam in ation . Th is m em ory th ere ore resid es in th e p recon sciou s m in d. Th e u n con sciou s
m in d con tain s rep ressed th ou gh ts an d eelin gs, wh ich are n ot availab le to th e con sciou s
m in d . Th e con sciou s m in d con tain s th ou gh ts th at a p erson is cu rren tly aware o . Th e
id con tain s in stin ctive sexu al an d aggressive d rives an d is n ot in lu en ced by extern al
reality. Th e ego also con trols th e exp ression o th e id, su stain s satis yin g in terp erson al
relation sh ip s, an d, th rou gh reality testin g, m ain tain s a sen se o reality abou t th e body an d
th e extern al world (see also an swer to Qu estion 9).
9. The answer is D. Th e su p erego is associated with m oral valu es an d con scien ce, an d
con trols im p u lses o th e id. Th is teen ager wh o steals rom am ily m em b ers an d rien d s an d
tortu res th e am ily cat is sh owin g de icien cies in h is su p erego. Ch ildren an d adolescen ts
u n d er age 18 years, wh o h ave p oor su p erego d evelop m en t, m ay be diagn osed with
con d u ct disord er (see Ch ap ter 15).
10. The answer is H. Th e residen t’s b eh avior in dealin g with th is p atien t re lects h is u se o th e
de en se m ech an ism o in tellectu alization . Th e resid en t h as u sed h is tech n ical kn owledge
to avoid exp erien cin g th e em otion associated with tellin g th e p atien t th at sh e is dyin g.
11. The answer is J . In disp lacem en t, th e m an’s p erson ally u n accep table an gry eelin gs toward
h is wi e are taken ou t on h is ch ild ren .
12. The answer is I. In su blim ation , th e su rgeon rerou tes h is u n con sciou s, u n accep table wish
or com m ittin g a violen t act to a socially accep table rou te (cu ttin g p eop le du rin g su rgery).
13. The answer is E. Usin g p rojection , th e h u sban d attribu tes h is own u n con sciou s,
u n accep table sexu al eelin gs toward an oth er wom an to h is wi e.
14. The answer is G. In reaction orm ation , th e m an d en ies h is u n con sciou s ear o lyin g an d
em b races th e op p osite id ea by statin g th at h e loves airp lan es.
15. The answer is C. Usin g den ial, th is p atien t h as seem in gly orgotten an asp ect o extern al
reality, th at is, th e letter abou t h is p roblem atic PSA test.
16. The answer is F. Th is p atien t wh o relates th at sh e wakes u p u lly dressed at least twice
a week an d receives p h on e calls rom m en wh om sh e does n ot rem em ber m eetin g is
exh ib itin g d issociative id en tity d isord er (m u ltip le p erson ality disorder). Dissociation ,
sep aratin g p art o on e’s con sciou sn ess rom real li e even ts, is th e de en se m ech an ism
u sed by in d ivid u als with th is d isord er. It is likely th at th is p atien t m et th e m en wh o h ave
h er p h on e n u m ber b u t d oes n ot rem em ber m eetin g th em becau se at th at tim e sh e was
sh owin g an oth er p erson ality (see also Ch ap ter 14).
17. The answer is A. Regression , goin g b ack to a less m atu re way o b eh avin g, is th e d e en se
m ech an ism u sed by th is wom an sch ed u led or su rgery th e n ext d ay wh o in sists th at h er
m oth er stay overn igh t in th e h osp ital with h er.
18. The answer is I. Th e u se u l em p loym en t in h er abstract art o th is wom an’s “m essy”
ten d en cies is an exam p le o th e d e en se m ech an ism o su b lim ation .
19. The answer is K. Th is m an is u sin g th e p artly con sciou s de en se m ech an ism o su p p ression
d u rin g th e tim e th at h e is arran gin g or h is work to be don e by som eon e else be ore goin g
to th e h osp ital.
20. The answer is G. Th is wom an wh o bakes cookies or h er ab u sive ath er is m an agin g h er
h ostility toward h im by u sin g th e d e en se m ech an ism o reaction orm ation . In th is de en se
m ech an ism , a p erson adop ts beh avior th at is op p osite to the way sh e really eels, th at is,
th is wom an eels in ten se an ger toward h er ath er bu t sh ows carin g beh avior toward h im .
21. The answer is B. Th is p atien t with obsessive–com p u lsive disorder is u sin g th e de en se
m ech an ism o u n d oin g. Cou n tin g th e ligh ts rem oves or “u n does” th e stu den t’s an xiety,
wh ich is likely to be related to h is sch ool p er orm an ce.
c ha pte r
7 Learn in g Th eory
I. OVERVIEW
A. Learn in g is th e acqu isition o n ew beh avior p attern s.
C. Learn in g m eth ods are th e basis o behavioral treatment techniques , su ch as system atic desen -
sitization , aversive con dition in g, lood in g, bio eedback, token econ om y, an d cogn itive th er-
apy (see Ch ap ter 17).
B. In sensitization, rep eated stim u lation resu lts in an in creased resp on se (e.g., a ch ild wh o is
a raid o sp iders eels m ore an xiety each tim e h e en cou n ters a sp ider).
65
66 BRS Behavioral Science
D. Aversive conditioning. An u n wan ted beh avior (e.g., settin g ires) is p aired with a p ain u l
or aversive stim u lu s (e.g., a p ain u l electric sh ock). An association is created between th e
u n wan ted beh avior ( ire-settin g) an d th e aversive stim u lu s (p ain ) an d th e ire-settin g ceases.
E. Learned helplessness
1. An an im al receives a series o p ain u l electric sh ocks rom wh ich it is unable to escape.
2. By classical con d ition in g, th e an im al learn s th at th ere is an association between an aver-
sive stim u lu s (e.g., p ain u l electric sh ock) an d th e in ability to escap e.
3. Su bsequ en tly, th e an im al m akes n o attem p t to escap e wh en sh ocked or wh en aced with
an y n ew aversive stim u lu s; in stead , th e an im al becom es hopeless and apathetic.
4. Learn ed h elp lessn ess in an im als m ay b e a m odel system or depression (o ten ch aracter-
ized by h op elessn ess an d ap ath y) in h u m an s.
5. An tidep ressan t treatm en t in creases escap e attem p ts in an im al m odels.
B. Features
1. Th e likelih ood th at a behavior will occu r is increased by positive or negative reinforcement
an d decreased by punishment or extinction (Table 7.1).
Chapter 7 Learning Theory 67
Positive rein- Behavior is Child increases his kind Reward or reinforcement (praise) increases
forcement increased by behavior toward his desired behavior (kindness toward brother)
reward younger brother to get A reward can be praise or attention as well as a
praise from his mother tangible reward like money
Negative rein- Behavior is Child increases his kind Active avoidance of an aversive stimulus
forcement increased by behavior toward his (being scolded) increases desired behavior
avoidance or younger brother to avoid (kindness toward brother)
escape being scolded
Punishment Behavior is Child decreases his hitting Delivery of scolding decreases unwanted
decreased by an behavior after his behavior (hitting brother) rapidly but not
aversive stimulus mother scolds him permanently
Extinction Behavior is Child stops his hitting Extinction is more effective than punishment for
eliminated by behavior when the long term reduction in unwanted behavior
nonreinforcement behavior is ignored There may be an initial increase in hitting
behavior before it disappears
Continuous Presented after every A teenager receives a candy bar each Behavior (putting in a dollar to receive
response time she puts a dollar into a vending candy) is rapidly learned but disappears
machine. One time she puts a dollar rapidly (has little resistance to extinc
in and nothing comes out. She never tion) when not reinforced (no candy
buys candy from the machine again comes out)
Fixed ratio Presented after a A man is paid $10 for every five hats he Fast response rate (many hats are made
designated number makes. He makes as many hats as he quickly)
of responses can during his shift
Fixed Presented after a A student has an anatomy quiz every The response rate (studying) increases
interval designated amount Friday. He studies for 10 min on toward the end of each interval (1 wk)
of time Wednesday nights, and for 2 h on
Thursday nights
When graphed, the response rate forms
a scalloped curve
Variable Presented after a After a slot machine pays off $5 for a The behavior (playing the slot machine)
ratio random and unpre single quarter, a woman plays $50 continues (is highly resistant to
dictable number of in quarters despite the fact that she extinction) despite the fact that it is only
responses receives no further payoffs reinforced (winning money) after a large
but variable number of responses
Variable Presented after a ran After 5 min of fishing in a lake, a man The behavior (fishing) continues (is highly
interval dom and unpredict catches a large fish. He then spends resistant to extinction) despite the
able amount of time 4 h waiting for another bite fact that it is only reinforced (a fish is
caught) after varying time intervals
68 BRS Behavioral Science
1. A grad e sch ool p rin cip al h as 1 week to try 3. For th is scen ario, wh ich elem en t
ou t a n ew f re-alarm system or th e sch ool. rep resen ts th e u n con dition ed resp on se?
He decides to test th e system th ree tim es (A) Stom ach growlin g in resp on se to th e
du rin g th e week. Th e f rst tim e th e alarm is wh ite van
sou n d ed, all o th e stu d en ts leave th e sch ool (B) Stom ach growlin g in resp on se to p izza
with in 5 m in u tes. Th e secon d tim e, it takes (C) Th e wh ite van
th e stu den ts 15 m in u tes to leave th e sch ool. (D) Pairin g th e wh ite van with gettin g p izza
Th e th ird tim e th e alarm is sou n ded, th e (E) Pizza
stu d en ts ign ore it. Th e stu den ts’ resp on se to
th e f re alarm th e th ird tim e it is sou n ded is 4. For th is scen ario, wh ich elem en t
m ost likely to h ave b een learn ed by rep resen ts th e u n con dition ed stim u lu s?
(A) sen sitization (A) Stom ach growlin g in resp on se to th e
(B) h abitu ation wh ite van
(C) classical con d ition in g (B) Stom ach growlin g in resp on se to p izza
(D) ixed ratio rein orcem en t (C) Th e wh ite van
(E) con tin u ou s rein orcem en t (D) Pairin g th e wh ite van with gettin g p izza
(F) variab le ratio rein orcem en t (E) Pizza
(G) p u n ish m en t
5. For th is scen ario, wh ich elem en t
2. Wh en ever a 46-year-old m an visits h is rep resen ts th e con dition ed stim u lu s?
p h ysician , h is b lood p ressu re is elevated.
(A) Stom ach growlin g in resp on se to th e
When th e p atien t takes h is own blood
wh ite van
p ressu re at h om e, it is u su ally n orm al. Th e
(B) Stom ach growlin g in resp on se to p izza
doctor says th at wh ile oth er tests n eed to
(C) Th e wh ite van
be d on e, th e p atien t is p rob ab ly sh owin g
(D) Pairin g th e wh ite van with gettin g p izza
“wh ite-coat h yp erten sion .” For th is scen ario,
(E) Pizza
th e p atien t’s blood p ressu re in th e doctor’s
o f ce rep resen ts
6. In th e p ast, a ch ild h as on occasion
(A) th e u n con dition ed stim u lu s received m on ey or clean in g h is room .
(B) th e u n con dition ed resp on se Desp ite th e act th at h e h as n ot received
(C) th e con dition ed stim u lu s m on ey or clean in g h is room or th e p ast
(D) th e con dition ed resp on se m on th , th e ch ild’s room -clean in g beh avior
con tin u es (is resistan t to extin ction ). Th is
Questions 3–5 ch ild’s room -clean in g beh avior was p robably
learn ed u sin g wh ich o th e ollowin g
For th e p ast year, p izza h as b een sold rom a m eth od s?
wh ite van ou tsid e a h igh sch ool. Th e teen age
(A) Con tin u ou s rein orcem en t
stu den ts com p lain th at th ey are o ten em bar-
(B) Fixed ratio rein orcem en t
rassed b ecau se th eir stom ach s b egin to growl
(C) Fixed in terval rein orcem en t
wh en ever th ey see an y wh ite veh icle, even on
(D) Variab le ratio rein orcem en t
weeken d s. Th e p rin cip al th en b an s th e van
(E) Pu n ish m en t
rom sellin g p izza n ear th e sch ool an d th e
stu den ts’ stom ach s stop growlin g at th e sigh t
o wh ite veh icles.
69
70 BRS Behavioral Science
1. The answer is B. Th e stu d en ts’ resp on se to th e ire alarm is m ost likely to h ave been
learn ed by h abituation , th at is, desen sitization . In th is orm o learn in g, con tin u ed
exp osu re to a stim u lu s (th e ire alarm , in th is exam p le) resu lts in a d ecreased resp on se
to th e stim u lu s. Th u s, wh ile th e stu den ts resp on d qu ickly to th e ire alarm at irst, with
rep eated sou n din gs o th e alarm , th ey u ltim ately ail to resp on d to it. I sen sitization
h ad occu rred, th e stu d en ts wou ld h ave resp on d ed m ore qu ickly with each exp osu re to
th e alarm . In classical con dition in g, a n atu ral resp on se is elicited by a learn ed stim u lu s.
In op eran t con dition in g, rein orcem en t is a con sequ en ce o a beh avior th at alters th e
likelih ood th at th e beh avior will occu r again . Pu n ish m en t is th e in trodu ction o an
aversive stim u lu s th at redu ces th e rate o an u n wan ted beh avior, wh ile extin ction is th e
disap p earan ce o a learn ed beh avior wh en rein orcem en t is with h eld .
2. The answer is D. Th e p atien t’s elevated b lood p ressu re in th e doctor’s o ice is th e
con d ition ed (learn ed) resp on se. Th is resp on se resu lts rom an association th at h as b een
m ade by classical con d ition in g b etween th e doctor an d / or h is wh ite coat (con d ition ed
stim u lu s) an d som eth in g n egative in th e p atien t’s p ast (u n con d ition ed stim u lu s), a
reaction com m on ly called “wh ite-coat h yp erten sion .” Th e cu e th at th is resp on se is learn ed
is th at th e p atien t’s blood p ressu re is relatively n orm al wh en taken at h om e.
3. The answer is B. 4. The answer is E. 5. The answer is C. Th e u n con d ition ed stim u lu s (p izza)
p rodu ces th e u n con d ition ed resp on se (stom ach growlin g in resp on se to p izza). Th e
u n con dition ed resp on se is re lexive an d au tom atic an d does n ot h ave to be learn ed. Th e
u n con dition ed stim u lu s (p izza) is th e on ly elem en t h ere th at by itsel will elicit a n atu ral
GI re lex (stom ach growlin g). Th e wh ite van is an exam p le o th e con dition ed stim u lu s.
In th is scen ario, th e con dition ed or learn ed stim u lu s cau ses th e sam e resp on se as th e
u n con dition ed or u n learn ed stim u lu s on ly a ter it is p aired with p izza (stom ach growlin g
in resp on se to p izza).
6. The answer is D. Th is ch ild h as received m on ey on u n p redictable occasion s or clean in g
h is room . Beh avior learn ed in th is way (i.e., by variable ratio rein orcem en t) is very
resistan t to extin ction an d con tin u es even wh en it is n ot rewarded. Beh avior learn ed by
ixed sch edu les o rein orcem en t (ratio or in terval) is less resistan t to extin ction . Beh avior
learn ed by con tin u ou s rein orcem en t is least resistan t to extin ction . Pu n ish m en t is
aversive an d is aim ed at su p p ressin g an u n d esirable beh avior.
7. The answer is B. Th is b eh avior is an exam p le o m odelin g; th e ch ild wan ts to b ecom e
like th e doctor she adm ires. In stim u lu s gen eralization , a n ew stim u lu s th at resem bles a
con d ition ed stim u lu s cau ses a con d ition ed resp on se. Sh ap in g in volves rewardin g closer
an d closer ap p roxim ation s o th e wan ted beh avior u n til th e correct beh avior is ach ieved.
Im p rin tin g is th e ten den cy o organ ism s to m ake an association with an d th en ollow th e
72
Chapter 7 Learning Theory 73
irst th in g th ey see a ter birth or h atch in g. In learn ed h elp lessn ess, an association is m ade
between an aversive stim u lu s an d th e in ability to escap e.
8. The answer is E. Th is ch ild is sh owin g learn ed h elp lessn ess, in wh ich an association
is m ad e between an aversive stim u lu s (b eatin gs) an d th e in ability to escap e. A ter th e
b eatin gs, th is ch ild m akes n o attem p t to escap e bu t in stead becom es h op eless an d
ap ath etic wh en aced with an oth er beatin g. Learn ed h elp lessn ess m ay be a m odel system
or th e d evelop m en t o dep ression (see also an swer to Qu estion 7).
9. The answer is A. Th is b eh avior is an exam p le o stim u lu s gen eralization . In th is exam p le, it
occu rs wh en a n ew con dition ed stim u lu s (th e gran d m oth er’s wh ite jacket) th at resem bles
th e origin al con dition ed stim u lu s (th e n u rse’s wh ite u n i orm ) resu lts in th e con dition ed
resp on se (cryin g wh en h e sees h is gran dm oth er) (see also an swer to Qu estion 7).
10. The answer is A. Becau se th e beh avior (h ittin g th e dog) decreased, th e scoldin g th at th is
ch ild received is p rob ably p u n ish m en t. Both n egative an d p ositive rein orcem en t in crease
beh avior. Sh ap in g in volves reward in g closer an d closer ap p roxim ation s o th e wan ted
beh avior u n til th e correct b eh avior is ach ieved. In classical con dition in g, a n atu ral or
re lexive resp on se (b eh avior) is elicited by a learn ed stim u lu s (a cu e rom an in tern al or
extern al even t). (See also an swers to Qu estion s 11–16).
11. The answer is C. Becau se th e b eh avior (h ittin g th e d og) is in creased , th e scold in g th at
th is ch ild received is p rob ab ly p ositive rein orcem en t. Both n egative an d p ositive
rein orcem en t in crease b eh avior. Th e reward or rein orcem en t or th is h ittin g beh avior is
m ost likely to b e in creased atten tion rom th e ath er. Pu n ish m en t decreases beh avior.
12. The answer is B. Becau se th e beh avior (exercise) is in creased to avoid som eth in g n egative
(in su lin in jection s), th is is an exam p le o n egative rein orcem en t.
13. The answer is E. Th is com m on clin ical p h en om en on is an exam p le o classical
con d ition in g. In th is exam p le, a wom an com es in to th e h osp ital or an in traven ou s
(IV) ch em oth erapy treatm en t (u n con d ition ed stim u lu s). Th e ch em oth erapy dru g is
toxic an d sh e b ecom es n au seated a ter th e treatm en t (u n con dition ed resp on se). Th e
ollowin g m on th , wh en sh e en ters th e h osp ital lob by (con d ition ed stim u lu s), sh e b ecom es
n au seated (con d ition ed resp on se). Th u s, th e h osp ital wh ere th e treatm en ts took p lace
(con d ition ed stim u lu s) h as b ecom e p aired with ch em oth erapy (th e u n con dition ed
stim u lu s), wh ich elicited n au sea. Now, n au sea (con dition ed resp on se) can be elicited by
en terin g th e h osp ital lobby (con dition ed stim u lu s), even th ou gh sh e h as n ot yet received
th e m ed ication . In op eran t con dition in g, beh avior is learn ed by its con sequ en ces.
Mod elin g is a typ e o ob servation al learn in g. Sh ap in g in volves rewardin g closer an d closer
ap p roxim ation s o th e wan ted b eh avior u n til th e correct beh avior is ach ieved. Extin ction is
th e disap p earan ce o a learn ed beh avior wh en rein orcem en t is with h eld.
14. The answer is E. Via classical con dition in g, th e p atien t h as m ade an association between
th e sou n ds on th e tap e an d sleep in g, so sh e n ow alls asleep as soon as sh e h ears th e
sou n ds.
15. The answer is C. 16. The answer is B. In th is exam p le, th e ch ild’s cryin g beh avior in creases
as a resu lt o p ositive rein orcem en t, bein g p icked u p by h is m oth er each tim e h e cries. Th e
m oth er’s beh avior (p ickin g u p th e ch ild ) in creases as a resu lt o n egative rein orcem en t;
sh e p icks h im u p to avoid h earin g h im cry.
17. The answer is A. 18. The answer is C. 19. The answer is D. 20. The answer is B. Th e p ain u l
b lood with d rawal p roced u re is th e u n con d ition ed stim u lu s. Th e an tisep tic od or in th e
clin ic h as b ecom e associated with th e p ain u l p roced u re an d elicits th e sam e resp on se;
it is th ere ore th e con d ition ed stim u lu s. Th e con d ition ed resp on se, cryin g in resp on se
to th e sm ell o th e an tisep tic, h as b een learn ed . Becau se cryin g in resp on se to th e p ain
o an in jection is au tom atic an d d oes n ot h ave to b e learn ed , it is th e u n con d ition ed
resp on se.
Clin ical Assessm en t o
c ha pte r
8 Patien ts with Beh avioral
Sym p tom s
74
Chapter 8 Clinical Assessment of Patients with Behavioral Symptoms 75
C. Normal intelligence
1. As stated above, an IQ o 100 m ean s th at th e MA an d CA are ap p roxim ately th e sam e.
Normal or average IQ is in the range of 90–109.
2. Th e stan dard deviation (see Ch ap ter 26) in IQ scores is 15. A p erson with an IQ th at is
m ore th an 2 stan d ard d eviation s below th e m ean (IQ 70) is u su ally con sid ered in tellectu -
ally d isab led (see Ch ap ter 2). Classifications of intellectual disability (th e overlap or gap in
categories is related to di eren ces in testin g in stru m en ts) are:
a. Mild (IQ 50–70).
b. Mod erate (IQ 35–55).
c. Severe (IQ 20–40).
d. Pro ou n d (IQ <20).
3. A score b etween 71 an d 84 in dicates borderline in tellectu al u n ction in g.
4. A p erson with an IQ m ore th an 2 stan dard deviation s above th e m ean (IQ >130) h as su p e-
rior in telligen ce.
D. The Wechsler intelligence tests and the Vineland Adaptive Behavior Scales
1. Th e Wech sler Ad u lt In telligen ce Scale—Fou rth Edition (WAIS-IV) is th e m ost com m on ly
u sed IQ test.
2. Th e WAIS-R h as ou r in dex scores: Verbal Comprehension Index (VCI), Working Memory
Index (WMI), Perceptual Reasoning Index (PRI), an d Processing Speed Index (PSI).
a. Th e VCI an d WMI togeth er m ake u p th e verbal IQ.
b. Th e PRI an d PSI togeth er m ake u p th e performance IQ.
c. Th e Full Scale IQ (FSIQ) is gen erated by all ou r in dex scores.
3. Th e Wech sler In telligen ce Scale or Ch ildren (WISC) is u sed to test in telligen ce in ch ildren
6–16½ years o age.
4. Th e Wech sler Presch ool an d Prim ary Scale o In telligen ce (WPPSI) is u sed to test in tel-
ligen ce in ch ildren 4–6½ years o age.
5. Th e Vineland Adaptive Behavior Scales are u sed to evalu ate skills or daily livin g (e.g.,
d ressin g, u sin g th e telep h on e) in p eop le with in tellectu al disability (see Ch ap ter 2) an d
oth er ch allen ges (e.g., th ose with im p aired vision or h earin g).
Minnesota The most commonly used Objective test “I avoid most social
Multiphasic objective personality test Patients answer 567 true (T) or false (F) situations” (T or F)
Personality Useful for primary care questions about themselves “I often feel jealous”
Inventory physicians because no Clinical scales include depression, paranoia, (T or F)
(MMPI-2) training is required for schizophrenia, and illness anxiety disorder “I like being active”
administration and scoring Validity scales identify trying to look ill (T or F)
Evaluates attitude of the patient (“faking bad,” i.e., malingering) or trying to
toward taking the test look well (“faking good”)
Rorschach Test The most commonly used Projective test
projective personality test Patients are asked to interpret 10 bilaterally
Used to identify thought symmetrical inkblot designs (e.g.,
disorders and defense “Describe what you see in this figure”)
mechanisms
Thematic Stories are used to evaluate Projective test
Apperception unconscious emotions and Patients are asked to create verbal
Test (TAT) conflicts scenarios based on 30 drawings depicting
ambiguous situations (e.g., “Using this
picture, make up a story that has a
beginning, a middle, and an end”)
B. Objective personality tests (e.g., th e Min n esota Mu ltip h asic Person ality In ven tory [MMPI]
an d th e Million Clin ical Mu ltiaxial In ven tory [MCMI]) are based on qu estion s th at are easily
scored an d statistically an alyzed.
C. Projective personality tests (e.g., th e Rorsch ach Test, th e Th em atic Ap p ercep tion Test
[TAT], an d th e Sen ten ce Com p letion Test) req u ire th e su b ject to in terp ret th e q u estion s.
Resp on ses are assu m ed to b e b ased on th e su b ject’s m otivation al state an d d e en se
m ech an ism s.
Uses o som e o th ese p erson ality tests are described in Table 8.1.
General Presentation
Appearance A 40-year-old male patient looks older than his age but is well groomed. He
Behavior seems defensive when asked about his past experiences with drugs and
Attitude toward the interviewer denies that he has ever used them
Level of consciousness He has a Glasgow Coma Scale score of 15 (see Table 5.4)
Cognition
Orientation, memory, attention, A 55-year-old female patient is oriented to person, place, and time and shows
concentration; cognitive, spatial, and normal memory (cognitive ability), understanding of three-dimensional
abstraction abilities; and speech (volume, space (spatial ability), and can tell you how an apple and an orange are
speed, and articulation) alike (abstraction ability). However, she speaks too quickly and is difficult
to understand
Mood and Affect
Described (mood) and demonstrated (affect) A 35-year-old male patient describes feeling “low” and shows less external
emotions expression of mood than expected (depressed with a restricted affect)
Match of emotions with current events
Thought
Form or process of thought A 40-year-old female patient tells you, in excessive detail (circumstantiality:
Thought content (e.g., delusion) problem in process of thought), that the Mafia is after her (a delusion: See
Table 11.1)
Perception
Illusion (see Table 11.1) A 12-year-old girl tells you that the clothes in her closet look like a person is in
Hallucination (see Table 11.1) there (an illusion). She then describes hearing voices (a hallucination)
J udgment and Insight A 38-year-old woman tells you that she would open a stamped letter found on
the sidewalk to see if it contained money. She also says that she knows
this would be dishonest (normal, insightful response)
Reliability A 55-year-old patient correctly provides the details of his previous illnesses
(a reliable patient)
Control of Aggressive and Sexual Impulses A 35-year-old man tells you that he often overreacts emotionally, although
there is little provocation (poor impulse control)
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80 BRS Behavioral Science
8. For determ in in g, usin g bilaterally 11. Th e m ost ap p rop riate test or evalu atin g
sym m etrical in kblots, which de en se abstract reason in g an d p roblem solvin g in a
m echan ism s are used by a 25-year-old 54-year-old em ale p atien t is th e
wom an , what is the m ost appropriate test? (A) TAT
(A) TAT (B) MMPI-2
(B) MMPI-2 (C) WISC-R
(C) WISC-R (D) Rorsch ach Test
(D) Rorsch ach Test (E) Vin elan d Social Matu rity Scale
(E) Vin elan d Social Matu rity Scale (F) WRAT
(F) WRAT (G) BDI-II
(G) BDI-II (H) Raskin Dep ression Scale
(H) Raskin Dep ression Scale (I) Wiscon sin Card Sortin g Test
(I) Wiscon sin Card Sortin g Test
12. A 24-year-old p atien t with sch izop h ren ia
9. For evalu atin g d ep ression in a 54-year-old tells th e p h ysician th at th e CIA is listen in g
m ale p atien t u sin g a sel -ratin g scale, wh at is to his telep h on e con versation s th rou gh h is
th e m ost ap p rop riate test? television set. Th is p atien t is d escribin g
(A) TAT (A) a h allu cin ation
(B) MMPI-2 (B) an illu sion
(C) WISC-R (C) clou d in g o con sciou sn ess
(D) Rorsch ach Test (D) blu n ted a ect
(E) Vin elan d Social Matu rity Scale (E) a d elu sion
(F) WRAT
(G) BDI-II
(H) Raskin Dep ression Scale
(I) Wiscon sin Card Sortin g Test
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82 BRS Behavioral Science
11. The answer is I. Th e Wiscon sin Card Sortin g Test is th e m ost ap p rop riate test or evalu atin g
abstract reason in g an d p roblem solvin g in a p atien t. In th is test, a p atien t is asked to sort
128 resp on se cards th at vary in color, orm , an d n u m ber.
12. The answer is E. A alse b elie , in th is case th at th e CIA is listen in g to on e’s telep h on e
con versation s th rou gh th e television set, is an exam p le o a delu sion . A h allu cin ation is a
alse p ercep tion , an d an illu sion is a m isp ercep tion o reality (see also Table 11.1). Clou d in g
o con sciou sn ess is th e in ab ility to resp on d to extern al even ts, wh ile blu n ted a ect is a
d ecreased d isp lay o em otion al resp on ses.
Su bstan ce-Related
c ha pte r
9 Disorders
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84 BRS Behavioral Science
Alcohol 136.9
Marijuana 19.3
Prescription agents (mainly nonmedical use of pain relievers) 6.5
Cocaine 1.5
Hallucinogen 1.3
Inhalants 0.5
Heroin 0.3
Source: Substance Abuse and Mental Health Services Administration, 2013.
3. Most su b stan ces can b e classi ied categorically as stimulants, sedatives, opioids, or halluci-
nogens an d related agen ts.
4. Most su b stan ces can b e adm in istered by a n u m ber o rou tes. Rou tes th at p rovide qu ick
access to th e blood stream , an d h en ce th e brain , are o ten p re erred by u sers (e.g., sn i in g
in to th e n ose [“sn ortin g] an d sm okin g rath er th an in gestin g).
II. STIMULANTS
A. Overview
1. Stim u lan ts are central nervous system activators th at in clu de ca ein e, n icotin e, am p h et-
am in es, an d cocain e.
2. Th e e ects o u se an d with drawal o th ese su bstan ces can be ou n d in Table 9.2.
C. Nicotine is a toxic su bstan ce p resen t in tobacco. Cigarette sm okin g decreases li e exp ectan cy
m ore th an th e u se o an y oth er su bstan ce. Sm okin g is in creasin g m ost in teen aged girls.
E. Cocaine
1. “Crack” an d “freebase ” are ch eap, sm okable orm s o cocain e; in exp en sive, p u re orm
cocain e is snorted.
2. Hyperactivity an d growth retardation are seen in newborns o m oth ers wh o u sed cocain e
du rin g p regn an cy.
3. Tactile hallucinations o bu gs crawlin g on th e skin (i.e., formication) are seen with th e u se
o cocain e (“cocain e bu gs”).
Chapter 9 Substance-Related Disorders 85
Psychological
Caffeine, nicotine Increased alertness and attention span Lethargy
Agitation and insomnia Mild depression of mood
Mild improvement in mood
Physical
Decreased appetite Increased appetite with slight weight gain
Increased blood pressure and heart rate Fatigue
(tachycardia) Headache
Increased gastrointestinal activity
Psychological
Amphetamines, cocaine Significant elevation of mood (lasting only 1 h Significant depression of mood
with cocaine) Strong psychological craving (peaking a
Increased alertness and attention span few days after the last dose)
Aggressiveness, impaired judgment Irritability
Psychotic symptoms (e.g., paranoid delusions
with amphetamines and formication with
cocaine)
Agitation and insomnia
Physical
Loss of appetite and weight Hunger (particularly with amphetamines)
Pupil dilation Pupil constriction
Increased energy Fatigue
Tachycardia and other cardiovascular effects,
which can be life threatening
Seizures (particularly with cocaine)
Reddening (erythema) of the nose due to
“snorting” cocaine
Hypersexuality
F. Neurotransmitter associations
1. Stim u lan t dru gs work p rim arily by in creasin g th e availability o dopamine (DA) in th e
brain .
2. Stim u lan t u se stimulates the release of DA and blocks the reuptake of DA. Th ese action s
resu lt in in creased availability o th is n eu rotran sm itter in th e syn ap se.
3. In creased a vailab ility o DA in th e syn ap se is ap p aren tly in volved in th e m ood -
elevatin g e ects o stim u lan ts an d op ioid s (th e “reward” system o th e b rain ). As in
sch izop h ren ia (see Ch ap ter 11), in creased DA availab ility m ay also resu lt in psychotic
symptoms .
III. SEDATIVES
A. Overview
1. Sed atives are central nervous system depressants th at in clu de alcoh ol, barbitu rates, an d
ben zod iazep in es.
2. Sed ative agen ts work p rim arily by increasing th e activity o th e in h ibitory n eu rotran sm it-
ter g-am in obu tyric acid (GABA).
3. Hosp italization o p atien ts or with drawal rom sedatives is p ru den t; th e with drawal syn -
drom e m ay in clu d e seizu res, p sych otic sym p tom s su ch as h allu cin ation s an d delu sion s,
an d card iovascu lar sym p tom s th at are life-threatening. Th e e ects o u se an d with drawal
o sed atives can b e ou n d in Tab le 9.3.
86 BRS Behavioral Science
Psychological
Alcohol, benzodiazepines, barbiturates Mild elevation of mood Mild depression of mood
Decreased anxiety Increased anxiety
Somnolence Insomnia
Behavioral disinhibition Psychotic symptoms (e.g., delusions and
formication)
Disorientation
Physical
Sedation Tremor
Poor coordination Seizures
Respiratory depression Cardiovascular symptoms such as tachycardia
and hypertension
B. Alcohol
1. Acu te associated p rob lem s
a. Traffic accidents, homicide, suicide , an d rape are correlated with th e con cu rren t u se o
alcoh ol.
b. Child physical an d sexual abuse , dom estic p artn er abu se, an d elder abu se are also asso-
ciated with alcoh ol u se.
2. Ch ron ic associated p roblem s
a. Thiamine deficiency resu ltin g in Wernicke’s syndrome an d u ltim ately in Korsakoff’s syn-
drome (see Ch ap ter 14) is associated with lon g-term u se o alcoh ol.
b. Liver dysfunction, gastroin testin al p roblem s (e.g., u lcers), an d redu ced li e exp ectan cy
also are seen in h eavy u sers o alcoh ol.
c. Fetal alcohol syndrome (in clu d in g acial ab n orm alities, redu ced h eigh t an d weigh t, an d
in tellectu al disability) is seen in th e o sp rin g o wom en wh o drin k du rin g p regn an cy.
d. A ch ild h ood h istory o p roblem s su ch as ADHD an d conduct disorder (see Ch ap ter 15)
correlates with alcoh olism in th e adu lt.
3. Identification of alcoholism. Becau se in d ividu al wh o over-u se alcoh ol com m on ly u se
den ial as a de en se m ech an ism (see Ch ap ter 6), p ositive resp on ses to in direct qu eries
su ch as th ose in th e CAGE questions can h elp a p h ysician iden ti y a p erson wh o h as a
p roblem with alcoh ol. Th e CAGE qu estion s are: “Do you ever
a. try to Cu t down on you r d rin kin g?”
b. get An gry wh en som eon e com m en ts on you r drin kin g?”
c. eel Gu ilty ab ou t you r drin kin g?”
d. take a drin k as an Eye-op en er in th e m orn in g?”
4. Intoxication
a. Legal in toxication is de in ed as 0.08%–0.15% blood alcohol concentration, dep en din g on
in dividu al state laws.
b. Com a occu rs at a blood alcoh ol con cen tration o 0.40%–0.50% in n on alcoh olics.
c. Psych otic sym p tom s (e.g., h allu cin ation s) m ay be seen in alcoh ol in toxication as well
as in with drawal (see below).
5. Delirium tremens (“the DTs”)
a. Alcohol withdrawal delirium (also called d eliriu m trem en s or “th e DTs”) m ay occu r d u r-
in g th e 1st week o with d rawal rom alcoh ol (m ost com m on ly on th e 3rd d ay o h osp i-
talization ). It u su ally occu rs in p atien ts wh o h ave been drin kin g h eavily or years.
b. Deliriu m trem en s is life threatening; th e m ortality rate is abou t 20%.
C. Barbiturates
1. Barbitu rates are u sed m ed ically as sleeping pills , sedatives, an tian xiety agen ts (tran qu il-
izers), an ticon vu lsan ts, an d an esth etics.
2. Frequ en tly u sed an d over-u sed b arb itu rates in clu de am obarbital, p en tobarbital, an d
secobarb ital.
Chapter 9 Substance-Related Disorders 87
3. Barbitu rates cau se resp iratory d ep ression an d h ave a low safety margin. As su ch , th ey are
very dan gerou s in overd ose.
D. Benzodiazepines
1. Ben zodiazep in es are u sed m edically as antianxiety agents , sedatives, m u scle relaxan ts,
an ticon vu lsan ts, an d an esth etics an d to treat alcohol withdrawal (p articu larly lon g-actin g
agen ts su ch as ch lordiazep oxide an d diazep am [see Ch ap ter 16]).
2. Ben zodiazep in es h ave a high safety margin u n less taken with an oth er sedative, su ch as
alcoh ol.
3. Flumazenil (Mazicon , Rom azicon ), a ben zodiazep in e recep tor an tagon ist, can reverse th e
e ects o ben zodiazep in es in cases o overdose.
IV. OPIOIDS
A. Overview
1. Narcotics or op ioid dru gs in clu d e agents used medically as analgesics (e.g., m orp h in e) as
well as dru gs u sed illegally (e.g., h eroin ). Th e e ects o u se an d with drawal o op ioids can
b e ou n d in Table 9.4.
2. Com p ared to m edically u sed op ioids su ch as m orp h in e an d m eth adon e, illegal op ioids
su ch as heroin are m ore p oten t, cross th e blood–brain barrier m ore qu ickly, h ave a aster
on set o action , an d h ave more euphoric action.
3. In con trast to barbitu rate with drawal, wh ich m ay be atal, death from withdrawal of opioids
is rare u n less a seriou s p h ysical illn ess is p resen t.
t a b l e 9.5 Management (in Order of Utility, Highest to Lowest) of Use of Sedatives, Opioids,
Stimulants, and Hallucinogens and Related Agents
Minor Stimulants: Caffeine, Eliminate or taper from the diet Peer support group (e. g., “Smokenders”)
nicotine Analgesics to control headache due to Antidepressants (particularly bupropion
withdrawal [Zyban]) to prevent smoking
Support from family members or
nonsmoking physician
Hypnosis to prevent smoking
Nicotine-containing gum, patch, or nasal
spray (efficacy is equivocal)
Stimulants: Amphetamines, Benzodiazepines to decrease agitation Education for initiation and maintenance
cocaine Antipsychotics to treat psychotic symptoms of abstinence
Medical and psychological support
Sedatives: Alcohol, Hospitalization Education for initiation and maintenance
benzodiazepines, Flumazenil (Mazicon) to reverse the effects of of abstinence
barbiturates benzodiazepines Specifically for alcohol: Alcoholics
Substitution of long-acting barbiturate (e.g., Anonymous (AA) or other peer support
phenobarbital) or benzodiazepine (e.g., group (12-step program), disulfiram
chlordiazepoxide [Librium] in decreasing (Antabuse), psychotherapy, behavior
doses); IV diazepam (Valium), lorazepam therapy, naloxone (Narcan), naltrexone
(Ativan), or phenobarbital if seizures occur (ReVia), acamprosate (Campral),
Specifically for alcohol: Thiamine (vitamin B1) topiramate (Topamax)
and restoration of nutritional state
Opioids: Heroin, methadone, Hospitalization and naloxone (Narcan) for Methadone or buprenorphine (Subutex)
opioids used medically overdose maintenance program
Clonidine (alpha 2-agonist) to stabilize Naltrexone or buprenorphine plus
the autonomic nervous system during naloxone (Suboxone) used
withdrawal prophylactically to block the effects of
Substitution of long-acting opioid (e.g., opioids
methadone) in decreasing doses to Narcotics Anonymous (NA) or other peer
decrease withdrawal symptoms support program
Hallucinogens and Related Calming or “talking down” the patient Education for initiation and maintenance
Agents: Marijuana, Benzodiazepines to decrease agitation of abstinence
hashish, LSD, PCP, Antipsychotics to treat psychotic symptoms
psilocybin, mescaline
PCP, phencyclidine; LSD, lysergic acid diethylamide.
Psychological
Cannabis (marijuana, hashish), Altered perceptual states (auditory and visual Few, if any,
lysergic acid diethylamide (LSD), hallucinations, alterations of body image, distortions psychological
phencyclidine (PCP) or “angel dust,” of time and space) withdrawal symptoms
psilocybin, mescaline Elevation of mood
Impairment of memory (may be long term)
Reduced attention span
“Bad trips” (frightening perceptual states)
“Flashbacks” (a re-experience of the sensations
associated with use in the absence of the drug even
months after the last dose)
Physical
Impairment of complex motor activity Few, if any, physical
Cardiovascular symptoms withdrawal symptoms
Sweating
Tremor
Nystagmus (PCP)
B. Marijuana
1. Tetrah yd rocan n ab in ol (THC) is th e p rim ary active com p ou n d ou n d in m ariju an a.
2. In low doses, m ariju an a increases appetite an d relaxation an d cau ses con ju n ctival
redden in g.
3. Ch ron ic u sers exp erien ce lung problems associated with sm okin g an d a decrease in m oti-
vation (“the amotivational syndrome ”) ch aracterized by lack o desire to work an d in creased
ap ath y.
4. Alth ou gh it is n ot legal in all o th e Un ited States, marijuana or m edical u se is p erm itted
in m ore th an 25 states an d Wash in gton , DC, p rim arily or treatin g glau com a an d can -
cer treatm en t–related n au sea an d vom itin g. Con trolled sale o m ariju an a or recreation al
p u rp oses is allowed in Colorado, Wash in gton State, Oregon , Alaska an d th e District o
Colu m bia an d will soon be legal in oth er states as well.
VII. MANAGEMENT
A. Management of substance-related disorders ran ges rom ab stin en ce an d p eer su p p ort grou p s
to dru gs th at b lock p h ysical an d p sych ological with drawal sym p tom s.
B. Man agem en t o with d rawal sym p tom s in clu des im m ed iate treatm en t or detoxifica-
tion (“detox”) an d exten ded m an agem en t aim ed at p reven tin g relap se (“maintenance ”)
(Tab le 9.5).
D. Dual diagnosis or m en tally ill–ch em ically add icted (MICA) p atien ts requ ire treatm en t or
b oth su b stan ce-related d isorders an d th e com orbid p sych iatric illn ess (e.g., m ajor dep res-
sion ), o ten in a sp ecial u n it in th e h osp ital.
Emergency Department Observation Seen with Use of Seen with Withdrawal from
Pupil dilation Stimulants Opioids
Hallucinogens (e.g., LSD) Alcohol and other sedatives
Pupil constriction Opioids Stimulants
Psychotic symptoms (e.g., Stimulants Alcohol and other sedatives
hallucinations, delusions) Alcohol
Hallucinogens
Cardiovascular symptoms Stimulants Alcohol and other sedatives
LSD, lysergic acid diethylamide.
Review Test
1. The answer is D. 2. The answer is E. Th e m ost likely cau se o th is p atien t’s sym p tom s o
sweatin g, m u scle ach es, stom ach cram p s, diarrh ea, ever, ru n n y n ose, goose bu m p s, an d
d ilated p u p ils is h eroin with drawal. Wh ile alcoh ol with drawal m ay be associated with
p u p il dilation , alcoh ol u se an d with drawal an d am p h etam in e with drawal are less likely to
cau se th is con stellation o sym p tom s. O th e ch oices given , th e m ost e ective im m ediate
treatm en t or h eroin with d rawal is clon idin e to stabilize th e au ton om ic n ervou s system .
Psych otic sym p tom s are u n com m on in op ioid with drawal, an d th is p atien t does n ot n eed
an an tip sych otic. Naloxon e an d n altrexon e as well as stim u lan ts will worsen rath er th an
am eliorate th e p atien t’s with d rawal sym p tom s.
3. The answer is E. Alm ost 20 m illion Am erican s rep ort th at th ey u se m ariju an a. In
con trast, 1.5 m illion , 1.3 m illion , 0.5 m illion , an d 0.3 m illion rep ort th at th ey u se cocain e,
h allu cin ogen s, in h alan ts, an d h eroin , resp ectively.
4. The answer is D. Th e n ext step in m an agem en t is or th e p h ysician to ask th is p atien t th e
CAGE qu estion s. Positive an swers to an y two o th ese qu estion s or to th e last on e alon e
in dicate th at h e h as a p roblem with alcoh ol. Patien ts with su ch p roblem s typ ically u se
d en ial as a de en se m ech an ism an d so rarely believe or adm it th at th ey h ave a p roblem
with alcoh ol. Liver u n ction p rob lem s or p resen ce o th e stigm ata o alcoh olism (e.g., stria,
b roken b lood vessels on th e n ose) do n ot n ecessarily in dicate th e p atien t cu rren tly h as a
p rob lem with alcoh ol. It is in ap p rop riate or th e doctor to call th e p reviou s em p loyer or
in orm ation .
5. The answer is C. Th e am otivation al syn drom e (e.g., lack o in terest in gettin g a job or goin g
to sch ool) an d in creased ap p etite, p articu larly or sn ack oods, are ch aracteristically seen
in ch ron ic u sers o m ariju an a. Use o cocain e, h eroin , p h en cyclidin e (PCP), or lysergic
acid d ieth ylam ide (LSD) m ay cau se work-related p rob lem s b u t are less likely to in crease
ap p etite.
6. The answer is D. Like oth er stim u lan t dru gs, am p h etam in es su ch as “b ath salts” redu ce
ap p etite; u se can th u s resu lt in d ecreased bod y weigh t. Am p h etam in es also decrease
atigu e, in crease p ain th resh old, an d in crease libido.
7. The answer is E. Heroin u sers sh ow an elevated, relaxed m ood an d som n olen ce. Users are
m ost likely to b e you n g adu lt m ales.
8. The answer is C. Illegal d ru g u se is m ost com m on in p eop le 18–25 years o age.
9. The answer is B. Th e m ost likely cau se o trem or, tach ycardia, illu sion s (e.g., believin g th e
n u rse is an old rien d ), an d visu al an d tactile h allu cin ation s (e.g., orm ication —th e eelin g
o in sects crawlin g on th e skin ) in th is p atien t is alcoh ol with drawal, sin ce th e u se o alcoh ol
d u rin g th e p ast ew days o h osp italization is u n likely. His ractu red h ip m ay h ave been
su stain ed in th e all wh ile h e was in toxicated. Heroin u se an d h eroin an d am p h etam in e
with d rawal gen erally are n ot associated with p sych otic sym p tom s.
95
96 BRS Behavioral Science
10. The answer is D. Delu sion s an d oth er evid en ce o p sych osis are seen with th e u se o
cocain e. Th e in ten se eu p h oria p rodu ced by cocain e lasts on ly ab ou t 1 h ou r. Severe
p sych ological cravin g or th e d ru g p eaks 2–4 d ays a ter th e last dose, alth ou gh th ere m ay
be ew p h ysiologic sign s o with drawal. Cocain e in toxication is ch aracterized by agitation
an d irritability, n ot sedation .
11. The answer is A. Tach ycard ia, in creased p eristalsis, in creased en ergy, an d decreased
ap p etite are p h ysical e ects o stim u lan ts like ca ein e. Headach es are m ore likely to resu lt
rom with drawal rath er th an u se o stim u lan t dru gs.
12. The answer is B. 13. The answer is A. With drawal rom ben zodiazep in es is associated with
trem or, in som n ia, an d an xiety. Resp iratory d ep ression an d sedation are associated with th e
u se o , n ot with d rawal rom , sedative dru gs. O th e ch oices in Qu estion 13, seizu res are th e
m ost com m on li e-th reaten in g sym p tom th at th is wom an will ace over th e n ext ew days.
14. The answer is B. Tiredn ess an d h eadach e are seen with with drawal rom stim u lan ts. Wh ile
in creased ap p etite can be seen in with drawal rom all stim u lan ts, th e m ost in ten se h u n ger
is seen with with drawal rom am p h etam in es.
15. The answer is C. In th e Un ited States, th e grou p in wh ich sm okin g cu rren tly sh ows th e
largest in crease is teen aged em ales.
16. The answer is A. Th e m ajor m ech an ism o action o cocain e on n eu ral system s is to block
th e reu p take o dop am in e, th ereby in creasin g its availability in brain syn ap ses. In creased
availab ility o d op am in e is in volved in th e “reward” system o th e brain an d th e eu p h oric
e ects o stim u lan ts.
17. The answer is A. Weigh t gain com m on ly occu rs ollowin g with drawal rom stim u lan ts su ch
as n icotin e. Mild d ep ression o m ood an d leth argy are also seen . Lon g-term ab stin en ce is
u n com m on in sm okers; m ost sm okers wh o qu it relap se with in 2 years. Deliriu m trem en s
occu r with with drawal rom sedatives su ch as alcoh ol.
18. The answer is D. Th e b est resp on se to th is p atien t’s revelation abou t growin g an d u sin g
m ariju an a is to recom m en d e ective bu t sa er su bstitu tes, or exam p le, p rescrip tion
m ed ication s to treat h is n au sea an d lack o ap p etite. It is n eith er ap p rop riate n or n ecessary
or a p h ysician to rep ort th e p atien t’s action s to th e p olice. Also, th is HIV-p ositive
p atien t is likely to be m ore con cern ed abou t eelin g ill in th e sh ort-term th an lon g-term
con sequ en ces o m ariju an a u se su ch as resp iratory p roblem s.
19. The answer is D. Clon id in e acts via in h ib ition o n oradren ergic activity th rou gh
p resyn ap tic stim u lation o alp h a 2-adren ergic n eu ron s.
20. The answer is D. Th is 35-year-old p atien t is m ost likely to be with drawin g rom
secobarb ital, a barb itu rate. Barb itu rate with d rawal sym p tom s ap p ear abou t 12–20 h ou rs
a ter th e last dose an d in clu de an xiety, elevated h eart an d resp iration rates, p sych otic
sym p tom s (e.g., th e b elie th at som eon e is tryin g to kill h im ), con u sion , an d seizu res an d
can b e associated with li e-th reaten in g card iovascu lar sym p tom s. Th ere are ew p h ysical
with d rawal sym p tom s associated with m ariju an a, p h en cyclidin e (PCP), or lysergic acid
dieth ylam id e (LSD), an d th ose associated with h eroin are u n com ortable bu t rarely
p h ysically dan gerou s.
21. The answer is E. Th e violen t seizu res in th is 40-year-old wom an are m ost likely to be a sign
o alcoh ol with d rawal. Her laten ess an d p oor p er orm an ce at work over th e p ast 6 m on th s
are eviden ce th at sh e h as b een im p aired by alcoh ol. Sh e h as p robably becom e p h ysically
d ep en d en t on alcoh ol an d, becau se sh e b een with h er dyin g m oth er or at least 3 days,
h as n ot h ad th e op p ortu n ity to d rin k an d n ow is in with d rawal rom alcoh ol. It is m u ch
less likely th at th e seizu res are d u e to a p rim ary seizu re d isord er or cereb ral h em orrh age.
Th ere is n o reason or th is wom an to b e eign in g h er sym p tom s as wou ld be th e case in
m alin gerin g (see Ch ap ter 13), an d th e p h ysical in din gs su ggest an organ ic cau se rath er
th an a com p licated grie reaction (see Ch ap ter 3).
Chapter 9 Substance-Related Disorders 97
22. The answer is G. Th e p resen ce o HIV as well as sign s o sed ation an d eu p h oria in d icate
th at th is p atien t is an in traven ou s h eroin u ser.
23. The answer is A. Alcoh ol u se is com m on ly associated with au tom ob ile acciden ts.
24. The answer is C. Eryth em a o th e n ose is a resu lt o sn ortin g cocain e, an d dep ressed m ood
is seen in with drawal rom th e dru g.
25. The answer is J . Aggressiven ess an d p sych otic beh avior (ju m p in g rom on e roo top to
an oth er) in dicate th at th is p atien t h as u sed PCP.
26. The answer is K. Th is wom an , wh o h as b een actin g stran gely over a n u m ber o h ou rs an d
is exp erien cin g ou t-o -body exp erien ces (e.g., eelin gs o loatin g in th e air) an d illu sion s
(e.g., m istakin g th e overh ead ligh t or th e su n ), h as p robably taken LSD. Th e p atien t’s lack
o aggression or agitation in d icates th at th e h allu cin ogen sh e h as u sed is less likely to h ave
been PCP.
Norm al Sleep an d Sleep
c ha pte r
10 Disorders
B. Awake state. Beta an d alp h a waves ch aracterize th e electroen cep h alogram (EEG) o th e
awake in dividu al (Table 10.1).
1. Beta waves over th e ron tal lobes are com m on ly seen with active mental concentration.
2. Alpha waves over th e occip ital an d p arietal lobes are seen wh en a p erson relaxes with
closed eyes.
3. Sleep latency (p eriod o tim e rom goin g to bed to allin g asleep ) is typ ically less th an
10 m in u tes.
C. Sleep state. Du rin g sleep, b rain waves sh ow d istin ctive ch an ges (Table 10.1).
1. Sleep is d ivid ed in to rap id eye m ovem en t (REM) sleep an d non-REM sleep. Non -REM sleep
con sists o stages 1, 2, 3, and 4.
2. Map p in g th e tran sition s rom on e stage o sleep to an oth er du rin g th e n igh t p rodu ces a
stru ctu re kn own as sleep architecture (Figu re 10.1).
a. Sleep arch itectu re ch an ges with age. Th e elderly o ten h ave p oor sleep qu ality becau se
agin g is associated with reduced REM sleep and delta sleep (stages 3–4 or slow wave)
an d in creased n igh ttim e awaken in gs, leadin g to poor sleep efficiency (p ercen t o tim e
actu ally sp en t sleep in g p er p ercen t o tim e tryin g to sleep ) (Table 10.2).
98
Chapter 10 Normal Sleep and Sleep Disorders 99
% Sleep Time in
Sleep Stage Associated EEG Pattern (Cycles/Second cps) Young Adults Characteristics
Stages 3 Delta (slow-wave sleep) waves (1–3 cps) 25% (decreases Deepest, most relaxed stage of
and 4 with age) sleep; sleep disorders, such
as night terrors, sleepwalking
(somnambulism), and bed-
wetting (enuresis), may occur
Rapid eye “Sawtooth,” beta, alpha, and theta waves 25% (decreases Dreaming; penile and clitoral
movement with age) erection; increased pulse,
(REM) respiration, and blood pressure;
REM
sleep absence of skeletal muscle
movement
b. Sedative agents , su ch as alcoh ol, barbitu rates, an d ben zodiazep in es, also are associ-
ated with reduced REM sleep and delta sleep.
c. Most delta sleep occu rs du rin g th e first half of the sleep cycle .
d. Longest REM periods occu r d u rin g th e second half of the sleep cycle .
3. During REM sleep, high levels of brain and cardiovascular activity occur.
a. Average tim e to th e irst REM p eriod a ter allin g asleep (REM latency) is 90 minutes .
b. REM p eriods o 10–40 m in u tes each occu r abou t every 90 minutes th rou gh ou t th e n igh t.
c. A p erson wh o is dep rived o REM sleep on e n igh t (e.g., becau se o in adequ ate sleep,
rep eated awaken in gs, or sedative u se) h as in creased REM sleep th e n ext n igh t (REM
rebound).
1 2 3 4 5 6 7
Hours of s le e p in a typica l young a dult
FIGURE 10.1. Sleep architecture in typical young adult. (Adapted from Wedding D. Behavior & Medicine. St. Louis, MO:
Mosby Year Book; 1995:416.)
100 BRS Behavioral Science
Sleep Measure Typical Young Adult Depressed Young Adult Typical Elderly Adult
d. Exten ded REM d ep rivation or total sleep dep rivation m ay also resu lt in th e tran sien t
disp lay o psychopathology, u su ally an xiety or p sych otic sym p tom s.
A. Sleep–wake disorders in clu d e in som n ia, h yp ersom n olen ce, an d n arcolep sy an d are ch arac-
terized by p rob lem s in th e tim in g, qu ality, or am ou n t o sleep. Breathing-related sleep disor-
ders include sleep apnea, as well as circadian rhythm sleep disorder.
D. In som n ia, breath in g-related sleep disorder, an d n arcolep sy are described below.
III. INSOMNIA
A. In som n ia is difficulty falling asleep or staying asleep th at lasts for at least 1 month an d leads to
sleep in ess d u rin g th e d ay or cau ses p rob lem s u l illin g social or occu p ation al obligation s. It
is p resen t in at least 30% o th e p op u lation .
Chapter 10 Normal Sleep and Sleep Disorders 101
Sleep terror disorder Repetitive experiences of fright in which a person screams in fear during sleep
(usually normal in children)
The person cannot be awakened
The person has no memory of having a dream
Occurs during delta sleep
Onset in adolescence may indicate temporal lobe epilepsy
Nightmare disorder Repetitive, frightening dreams that cause nighttime awakenings
The person usually can recall the nightmare
Occurs during REM sleep
Sleepwalking disorder Repetitive walking around during sleep
No memory of the episode on awakening
Begins in childhood (usually 4–8 y of age)
Occurs during delta sleep
Circadian rhythm sleep disorder Inability to sleep at appropriate times
Delayed sleep phase type involves falling asleep and waking later than wanted
J et lag type lasts 2–7 d after a change in time zones
Shift work type (e.g., in physician training) can result in work errors
Nocturnal myoclonus Repetitive, abrupt muscular contractions in the legs from toes to hips
Causes nighttime awakenings
Treat with benzodiazepine, quinine, or antiparkinsonian, i.e., dopaminergic agent
(e.g., levodopa, ropinirole [Requip])
Restless legs syndrome Uncomfortable sensation in the legs necessitating frequent motion
Repetitive limb jerking during sleep
Causes difficulty falling asleep and nighttime awakenings
More common with aging, Parkinson’s disease, pregnancy, and kidney disease
Treat with antiparkinsonian agent, iron supplements, or magnesium supplements
Kleine-Levin syndrome and Recurrent periods of excessive sleepiness occurring almost daily for weeks to months
menstrual-associated Sleepiness is not relieved by daytime naps
syndrome (symptoms only in the Often accompanied by hyperphagia (overeating)
premenstruum) Kleine-Levin syndrome is more common in adolescent males
Sleep drunkenness Difficulty awakening fully after adequate sleep
Rare, must be differentiated from substance use or other sleep disorder
Associated with genetic factors
Bruxism Tooth grinding during sleep (stage 2)
Can lead to tooth damage and jaw pain
Treat with dental appliance worn at night or corrective orthodontia
REM sleep behavior disorder REM sleep without the typical skeletal muscle paralysis
While dreaming, patients can injure themselves or their sleeping partners
Associated with Parkinson’s disease and Lewy body disease
Treat with antiparkinsonian agent, REM suppressor (e.g., benzodiazepin), or
anticonvulsant (e.g., carbamazepine)
2. Bipolar disorder. Manic or hypomanic p atien ts h ave trou ble allin g asleep an d sleep ewer
h ou rs.
3. Anxious p atien ts o ten h ave trou ble allin g asleep.
B. Sleep ap n ea occu rs in 1%–10% of the population an d is related to dep ression , m orn in g h ead-
ach es, an d pulmonary hypertension. It m ay also resu lt in sudden death du rin g sleep in th e
elderly an d in in an ts.
V. NARCOLEPSY
A. Patien ts with n arcolep sy h ave sleep attacks (i.e., all asleep su dd en ly d u rin g th e d ay) d esp ite
h avin g a n orm al am ou n t o sleep at n igh t. Wh ile typ ical in am ou n t, th eir n igh ttim e sleep is
ch aracterized by decreased sleep latency, very short REM latency (<10 minutes), less total REM,
an d interrupted REM (sleep ragm en tation ).
B. Decreased REM sleep at n igh t leads to th e in tru sion o ch aracteristics o REM sleep (e.g.,
p aralysis, n igh tm ares) wh ile th e p atien t is awake resu ltin g in :
1. Hypnagogic or hypnopompic hallucinations. Th ese are stran ge p ercep tu al exp erien ces th at
occu r ju st as th e p atien t alls asleep or wakes u p, resp ectively, an d occu r in 20%–40% o
p atien ts.
2. Cataplexy. Th is is a su dd en p h ysical collap se cau sed by th e loss o all m u scle ton e a ter a
stron g em otion al stim u lu s (e.g., lau gh ter, ear) an d occu rs in 30%–70% o p atien ts.
3. Sleep paralysis. Th is is th e in ab ility to m ove th e body or a ew secon ds a ter wakin g.
C. Narcolep sy is u n com m on .
1. It occu rs m ost requ en tly in adolescents and young adults .
2. Th ere m ay be a genetic component.
3. Daytime naps allow th e p atien t to m ake u p som e lost REM sleep an d, as su ch , leave th e
p atien t eelin g re resh ed.
Chapter 10 Normal Sleep and Sleep Disorders 103
1. Th e p aren ts o a 5-year-old boy rep ort 4. Du rin g a sleep stu dy, a em ale p atien t’s
th at th e ch ild o ten scream s du rin g th e EEG sh ows p rim arily delta waves. Wh ich o
n igh t. Th ey are p articu larly con cern ed th e ollowin g is m ost likely to ch aracterize
becau se du rin g th ese d istu rb an ces, th e th is p atien t at th is tim e?
ch ild sits u p, op en s h is eyes, an d “looks (A) Clitoral erection
righ t th rou gh th em ,” an d th ey are u n able (B) Paralysis o skeletal m u scles
to awaken h im . Th e ch ild h as n o m em ory (C) Sleepwalkin g (som n am b u lism )
o th ese exp erien ces in th e m orn in g. (D) Nigh tm ares
Ph ysical exam in ation is u n rem arkable an d (E) In creased brain oxygen u se
th e ch ild is doin g well in kin dergarten .
Durin g th ese distu rban ces, th e ch ild’s 5. An 85-year-old p atien t rep orts th at h e
electroen cep h alogram is m ost likely to be sleep s p oorly. Sleep in th is p atien t is m ost
p rim arily ch aracterized by likely to be ch aracterized by in creased
(A) sawtooth waves (A) sleep e icien cy
(B) th eta waves (B) REM sleep
(C) K com p lexes (C) n igh ttim e awaken in gs
(D) delta waves (D) stage 3 sleep
(E) alp h a waves (E) stage 4 sleep
2. Du rin g a sleep stu dy, a p h ysician 6. A wom an rep orts th at m ost n igh ts
discovers th at a p atien t sh ows too little du rin g th e last year, sh e h as lain awake in
REM sleep du rin g th e n igh t. Th eoretically, bed or m ore th an 2 h ou rs b e ore sh e alls
to in crease REM sleep, th e p h ysician sh ou ld asleep. A ter th ese n igh ts, sh e is tired an d
give th e p atien t a m edication aim ed at orget u l an d m akes m istakes at work. O
in creasin g circu latin g levels o th e ollowin g, th e m ost e ective lon g-term
(A) seroton in treatm en t or th is wom an is
(B) n orep in ep h rin e (A) con tin u ou s p ositive airway p ressu re
(C) acetylch olin e (CPAP)
(D) dop am in e (B) an an tip sych otic agen t
(E) h istam in e (C) a sedative agen t
(D) a stim u lan t agen t
3. Du rin g a sleep stu dy, a m ale p atien t’s (E) develop m en t o a “sleep ritu al”
electroen cep h alogram (EEG) sh ows
p rim arily sawtooth waves. Wh ich o th e Questions 7 and 8
ollowin g is m ost likely to ch aracterize th is
p atien t at th is tim e? A 22-year-old m edical stu den t wh o goes to
(A) Pen ile erection sleep at 11 pm an d wakes at 7 a m alls asleep in
(B) Movem en t o skeletal m u scles laboratory every day. He tells the doctor th at
(C) Decreased blood p ressu re h e sees stran ge im ages as h e is allin g asleep
(D) Decreased brain oxygen u se an d som etim es ju st as h e wakes u p. He h as
(E) Decreased p u lse h ad a ew m in or car acciden ts th at occu rred
becau se h e ell asleep wh ile drivin g.
104
Chapter 10 Normal Sleep and Sleep Disorders 105
7. O th e ollowin g th e b est f rst step in 13. Th eta waves are m ost ch aracteristic o
m an agem en t o th is stu den t’s p rob lem is wh at sleep stage?
(A) con tin u ou s p ositive airway p ressu re (A) Stage 1
(CPAP) (B) Stage 2
(B) an an tip sych otic agen t (C) Stages 3 an d 4
(C) a sed ative agen t (D) REM sleep
(D) a stim u lan t agen t
(E) develop m en t o a “sleep ritu al” 14. Wh at sleep stage takes u p th e largest
p ercen tage o sleep tim e in you n g adu lts?
8. Wh ich o th e ollowin g is th is stu den t (A) Stage 1
m ost likely to exp erien ce? (B) Stage 2
(A) Lon g REM laten cy (C) Stages 3 an d 4
(B) Au ditory h allu cin ation s (D) REM sleep
(C) Tactile h allu cin ation s
(D) Delu sion s 15. Bed-wettin g is ch aracteristic o wh at
(E) Catap lexy sleep stage?
(A) Stage 1
Questions 9 and 10 (B) Stage 2
(C) Stages 3 an d 4
A p atien t rep orts th at h e is sleepy all d ay (D) REM sleep
desp ite h avin g 8 h ou rs o sleep each n igh t.
His wi e rep orts th at h is lou d sn orin g keep s 16. A 22-year-old stu den t in th e m iddle o
h er awake. f n als week tells h er d octor th at or th e last
2 weeks, sh e h as b een stu d yin g late in to th e
9. O th e ollowin g, th e b est f rst step in th e n ight an d h as started to h ave trou ble allin g
m an agem en t o th is p atien t is asleep. Wh at is th e doctor’s m ost ap p rop riate
(A) con tin u ou s p ositive airway p ressu re recom m en dation ?
(CPAP) (A) Exercise b e ore b ed tim e
(B) an an tip sych otic agen t (B) A large m eal be ore bedtim e
(C) a sed ative agen t (C) A glass o m ilk b e ore b ed tim e
(D) a stim u lan t agen t (D) A ixed wake-u p an d bed tim e
(E) develop m en t o a “sleep ritu al” sch ed u le
(E) A sh ort-actin g b en zodiazep in e at
10. O th e ollowin g, th is p atien t is m ost bedtim e
likely to b e
(A) dep ressed 17. A 45-year-old em ale p atien t rep orts
(B) aged 25 years th at over th e last 3 m on th s, sh e h as lost
(C) overweigh t h er ap p etite an d in terest in h er u su al
(D) u sin g a stim u lan t agen t activities an d o ten eels th at li e is n ot
(E) with d rawin g rom a sed ative agen t worth livin g. Com p ared with typ ical
sleep, in th is p atien t, th e p ercen tage
11. Sawtooth waves are m ost ch aracteristic o REM sleep, p ercen tage o delta sleep,
o wh at sleep stage? an d sleep laten cy, resp ectively, are m ost
(A) Stage 1 likely to
(B) Stage 2 (A) in crease, decrease, decrease
(C) Stages 3 an d 4 (B) in crease, decrease, in crease
(D) REM sleep (C) decrease, stay th e sam e, in crease
(D) decrease, decrease, in crease
12. Sleep spin dles, K com p lexes, an d bruxism (E) in crease, in crease, in crease
are m ost characteristic o what sleep stage?
(A) Stage 1
(B) Stage 2
(C) Stages 3 an d 4
(D) REM sleep
106 BRS Behavioral Science
24. A 21-year-old stu d en t wh o is p art o a 27. A 22-year-old stu den t rep orts th at h e
stu dy o circadian rh yth m s, sleep s in a cave alls asleep rep eatedly d u rin g th e d aytim e.
or 1 m on th with n o access to clocks or He also rep orts th at h e can n ot m ove or a
watch es. At th e en d o th e m on th , th e len gth ew m in u tes wh en h e f rst wakes u p in th e
o h er circad ian cycle is likely to be closest to m orn in g. I th e p atien t h as a sleep stu dy,
(A) 21 h ou rs wh ich o th e ollowin g sleep ch an ges is m ost
(B) 22 h ou rs likely to b e seen ?
(C) 23 h ou rs (A) In creased REM laten cy
(D) 24 h ou rs (B) Decreased REM laten cy
(E) 25 h ou rs (C) In creased Stage 2
(D) Decreased Stage 2
25. Th e wi e o a 62-year-old m an tells th e (E) In creased sleep laten cy
d octor th at or th e p ast year, h er h u sb an d
h as p u n ch ed an d kicked h er rep eated ly 28. A ter bein g asleep or 6 h ou rs d u rin g a
d u rin g th e n igh t. Wh en sh e wakes h im sleep stu dy, a h ealth y 28-year-old wom an
d u rin g th ese ep isod es, h er h u sban d relates wakes u p to u rin ate. Wh ich o th e ollowin g
th at h e h as been h avin g a d ream in wh ich ch an ges is m ost likely to be seen in h er EKG
h e is tryin g to escap e rom or f gh tin g with a at this tim e?
righ ten in g attacker. Over th e n ext ew years, (A) In creased h eart rate
th is m an is at in creased risk to develop (B) Decreased h eart rate
(A) Klein e-Levin syn drom e (C) In creased Q-T in terval
(B) sleep terror d isorder (D) Decreased Q-T in terval
(C) n octu rn al m yoclon u s (E) Atrial ib rillation
(D) Alzh eim er’s d isease
(E) Lewy body disease
1. The answer is D. Th is child dem on strates sleep terror disorder, wh ich is ch aracterized by
rep etitive occu rren ces o scream in g du rin g th e n igh t an d th e in ability to be awaken ed or to
rem em ber th ose exp erien ces in th e m orn in g. Sleep terrors typ ically occu r durin g delta sleep.
I th e ch ild were h avin g n igh tm ares, wh ich occu r in REM sleep, th e ch ild typ ically wou ld
awaken an d relate th e n atu re o h is righ ten in g dream s (see also an swer to Qu estion 19).
2. The answer is C. Acetylch olin e (Ach ) is in volved in both in creasin g REM sleep an d
in creasin g sleep e icien cy. In creased levels o dop am in e decrease sleep e icien cy.
In creased levels o n orep in ep h rin e decrease both sleep e icien cy an d REM sleep wh ile
in creased levels o seroton in in crease b oth sleep e icien cy an d delta (slow-wave) sleep.
3. The answer is A. Sawtooth waves ch aracterize REM sleep, wh ich is also associated with
p en ile erection ; dream in g; in creased p u lse, resp iration , an d blood p ressu re; an d p aralysis o
skeletal m u scles.
4. The answer is C. Delta waves ch aracterize sleep stages 3 an d 4 (slow-wave sleep ), wh ich is
also associated with som n am b u lism , n igh t terrors, ep isodic body m ovem en ts, an d en u resis.
Delta sleep is th e deep est, m ost relaxed stage o sleep. Clitoral erection , p aralysis o skeletal
m u scles, n igh tm ares, an d in creased b rain oxygen u se occu r d u rin g REM sleep.
5. The answer is C. Sleep in th e elderly is ch aracterized by in creased n igh ttim e awaken in gs,
decreased REM sleep, d ecreased d elta sleep, an d decreased sleep e icien cy.
6. The answer is E. Th e m ost e ective lon g-term m an agem en t or th is wom an with in som n ia
is th e develop m en t o a series o beh aviors associated with bedtim e (i.e., a “sleep ritu al”).
By th e p rocess o classical con dition in g (see Ch ap ter 7), th e sleep ritu al th en becom es
associated with goin g to sleep. Sleep ritu als can in clu de th in gs like takin g a warm b ath ,
p u llin g d own th e b lin d s, an d listen in g to sooth in g m u sic. Con tin u ou s p ositive airway
p ressu re is u sed to treat sleep ap n ea; stim u lan t agen ts are u sed to treat n arcolep sy; an d
an tip sych otics are u sed to treat p sych otic sym p tom s. Sedative agen ts h ave a h igh p oten tial
or m isu se an d, becau se th ey ten d to redu ce REM an d delta sleep, th eir u se m ay resu lt in
sleep o p oorer qu ality.
7. The answer is D. 8. The answer is E. Th is m edical stu den t wh o alls asleep in laboratory
every day desp ite a n orm al am ou n t o sleep at n igh t p robably h as n arcolep sy. O th e listed
ch oices, th e m ost e ective m an agem en t or n arcolep sy is th e adm in istration o stim u lan t
agen ts su ch as m od a in il. Sedative agen ts are n ot u se u l or n arcolep sy. In n arcolep sy,
sh ort REM laten cy, sleep p aralysis, an d catap lexy occu r. Th e stu d en t’s stran ge p ercep tu al
exp erien ces as h e is allin g asleep an d wakin g u p are h yp n agogic an d h yp n op om p ic
h allu cin ation s, resp ectively.
108
Chapter 10 Normal Sleep and Sleep Disorders 109
9. The answer is A. 10. The answer is C. Th is m an wh o sn ores an d rep orts th at h e is sleepy all
d ay desp ite h avin g 8 h ou rs o sleep each n igh t p robably h as obstru ctive sleep ap n ea. O
th e listed ch oices, th e b est irst step in m an agem en t o th is p atien t is con tin u ou s p ositive
airway p ressu re (CPAP). Sin ce ob esity is associated with obstru ctive sleep ap n ea, oth er
su ggestion s or th is p atien t wou ld in clu de weigh t loss. Use o stim u lan ts an d with drawal
rom sed atives are associated with wake u ln ess rath er th an th e daytim e sleep in ess
seen h ere. Also, m ost sleep ap n ea p atien ts are m iddle aged (age 40–60 years). Alth ou gh
d ep ression an d an xiety are associated with sleep p roblem s, th is m an’s sn orin g in dicates
th at h is sleep p roblem is m ore likely to h ave a p h ysical basis.
11. The answer is D. Sawtooth waves are p rim arily seen in REM sleep.
12. The answer is B. Sleep sp in d les, K com p lexes, an d b ru xism are p rim arily seen in stage 2
sleep.
13. The answer is A. Th eta waves are p rim arily seen in stage 1 sleep.
14. The answer is B. In you n g ad u lts, 45% o total sleep tim e is sp en t in stage 2 sleep. Five
p ercen t is sp en t in stage 1, 25% in REM, an d 25% in delta sleep.
15. The answer is C. Bed -wettin g occu rs p rim arily in stages 3 an d 4 (d elta) sleep.
16. The answer is D. Th e m ost ap p rop riate irst step in th e m an agem en t o th is 22-year-old
stu d en t wh o is h avin g tem p orary p roblem s with sleep du rin g in als week is to recom m en d
a ixed wake-u p an d bedtim e sch ed u le. Ben zodiazep in es are n ot ap p rop riate b ecau se o
th eir h igh p oten tial or m isu se an d p ossibility o cau sin g daytim e sedation in th is stu den t
du rin g exam in ation s. Th ese agen ts also decrease sleep qu ality by redu cin g REM an d
delta sleep. Exercise sh ou ld b e d on e early in th e day; i d on e b e ore bed tim e, it can b e
stim u latin g an d cau se wake u ln ess. A large m eal b e ore b ed tim e is m ore likely to in ter ere
with sleep th an to h elp sleep. Wh ile m an y p eop le believe th at m ilk h elp s in du ce sleep, th is
e ect h as n ever been sh own em p irically.
17. The answer is B. Th is wom an’s sym p tom s in dicate th at sh e is likely to be exp erien cin g a
m ajor dep ressive ep isod e (see Ch ap ter 12). Sleep in m ajor dep ression is associated with
in creased REM sleep, redu ced delta sleep, an d in creased sleep laten cy.
18. The answer is C. Th is sleep p attern in dicates th at th is wom an is eld erly. Sleep in eld erly
p atien ts is ch aracterized by in creased stage 1 an d stage 2 sleep, in creased n igh ttim e
awaken in gs, decreased REM sleep, an d m u ch redu ced or absen t d elta sleep.
19. The answer is B. Th is ch ild is exp erien cin g n igh tm are d isord er, wh ich occu rs d u rin g
REM sleep. In con trast to th e ch ild with sleep terror d isord er (see also an swer to
Qu estion 1), th is ch ild wakes u p an d can relate th e n atu re o h is righ ten in g d ream s.
Klein e-Levin syn d rom e is u su ally seen in ad olescen ts an d in volves recu rren t p eriod s
o h yp ersom n ia an d h yp erp h agia, each lastin g d ays to weeks. In sleep d ru n ken n ess, a
p atien t can n ot com e u lly awake a ter sleep, an d in circad ian rh yth m sleep d isord er, th e
in d ivid u al sleep s an d wakes at in ap p rop riate tim es. Noctu rn al m yoclon u s (m u scu lar
con traction s in volvin g th e legs) an d restless legs syn d rom e (u n com ortab le sen sation
in th e legs) occu r m ore com m on ly in m id d le-aged an d eld erly p eop le. Bru xism is tooth
grin d in g d u rin g sleep.
20. The answer is A. Th e act th at th is p atien t is an ad olescen t, as well as th e recu rren t p eriod s
o h yp ersom n ia an d h yp erp h agia each lastin g or weeks to m on th s, in d icate th at th is
p atien t h as Klein e-Levin syn drom e (an d see also an swer to Qu estion 19).
21. The answer is E. Circad ian rh yth m sleep disorder in volves th e in ability to sleep at
ap p rop riate tim es. Th is m an sh ows th e d elayed sleep p h ase typ e o th is disorder, wh ich
is ch aracterized by allin g asleep an d wakin g later th an wan ted . Wh en th e m an is able to
ollow h is p re erred sleep sch edu le (e.g., on weeken d s), h e sleep s well an d wakes re resh ed
(see also an swer to Qu estion 19).
110 BRS Behavioral Science
22. The answer is G. In restless legs syn d rom e, th ere are crawlin g, ach in g eelin gs in th e legs
m akin g it n ecessary or th e p atien t to m ove th em an d cau sin g d i icu lty in allin g asleep
(see also an swer to Qu estion 19).
23. The answer is C. Decreased REM sleep an d decreased delta sleep ch aracterize th e sleep o
p atien ts su ch as th is on e, wh o are takin g sedatives su ch as diazep am (a ben zodiazep in e),
barb itu rates, or alcoh ol.
24. The answer is E. At th e en d o th e m on th , th e len gth o th is stu den t’s circadian cycle in th e
absen ce o cu es rom th e ou tside world is likely to be close to 25 h ou rs.
25. The answer is E. Dream in g typ ically occu rs du rin g REM sleep. Becau se typ ically th ere
is m u scle aton ia du rin g REM sleep, th is m an wh o is m ovin g wh ile dream in g is sh owin g
sign s o REM sleep beh avior disorder. Th is disorder is associated with an in creased risk or
Parkin son’s disease an d Lewy body disease. Klein e-Levin syn drom e, sleep terror disorder,
n octu rn al m yoclon u s, an d Alzh eim er’s disease are n ot sp eci ically associated with REM
sleep b eh avior d isord er (see also an swer to Qu estion 19).
26. The answer is E. Ph ysostigm in e is a ch olin om im etic agen t u sed to treat m yasth en ia gravis.
Th e in crease in acetylch olin e resu ltin g rom treatm en t with th is agen t is m ost likely to
resu lt in in creased REM sleep in th is p atien t.
27. The answer is B. Th e sleep ch an ge m ost likely to be seen in th is stu d en t wh o is sh owin g
sym p tom s o n arcolep sy, th at is, excessive d aytim e sleep in ess an d sleep p aralysis, is
decreased REM laten cy. Alth ou gh in n arcolep sy th ere are n o sp eci ic ch an ges in Stage 2
sleep, sleep laten cy (th e tim e it takes to all asleep ) is typ ically d ecreased .
28. The answer is A. Th e m ost likely ch an ge seen in th e EKG o th is h ealth y you n g wom an is
in creased h eart rate. REM sleep, wh ich is ch aracterized by in creased h eart rate, occu rs
p rim arily in th e early m orn in g h ou rs (6 h ou rs a ter allin g asleep ) an d is th e stage o sleep
seen ju st b e ore wakin g (wakin g to u rin ate in th is qu estion ). Q-T in terval an d atrial rh yth m
ch an ges are n ot associated with wakin g d u rin g th e n igh t in h ealth y you n g adu lts.
Sch izop h ren ia Sp ectru m
c ha pte r
11 an d Oth er Psych otic
Disorders
I. SCHIZOPHRENIA
A. Overview
1. Sch izop h ren ia is a chronic, debilitating m en tal d isord er ch aracterized by p eriods o loss o
tou ch with reality (p sych osis); p ersisten t distu rban ces o th ou gh t, beh avior, ap p earan ce,
an d sp eech ; ab n orm al a ect; an d social with drawal.
2. Peak age of onset o sch izop h ren ia is 15–25 years for men and 25–35 years for women.
3. Sch izop h ren ia occu rs equally in men and women, all cultures, and all ethnic groups
stu d ied .
111
112 BRS Behavioral Science
C. Course. Sch izop h ren ia h as th ree phases: p rodrom al, active (i.e., p sych otic), an d residu al.
1. Prodromal sign s an d sym p tom s occu r p rior to th e irst p sych otic ep isode an d in clu de
avoidan ce o social activities; p h ysical com p lain ts; an d n ew in terest in religion , th e occu lt,
or p h ilosop h y.
2. In th e active phase , th e p atien t loses tou ch with reality. Disorders o p ercep tion , th ou gh t
con ten t, th ou gh t p rocesses, an d orm o th ou gh t (Table 11.1) occu r du rin g an acu te p sy-
ch otic ep isode.
3. In th e residual phase (tim e p eriod b etween p sych otic ep isodes), th e p atien t is in tou ch
with reality b u t d oes n ot beh ave n orm ally.
a. Th is p h ase is ch aracterized by negative symptoms .
b. In th is p h ase, th e p atien t typ ically sh ows in tact m em ory cap acity; is oriented to p erson ,
p lace, an d tim e; an d h as a normal level of consciousness (e.g., is alert).
4. Active p h ase sym p tom s m u st be p resen t or at least 1 month an d active p h ase an d/
or resid u al p h ase sym p tom s m u st b e p resen t or at least 6 months or th e diagn osis o
sch izop h ren ia.
D. Prognosis
1. Sch izop h ren ia u su ally in volves rep eated p sych otic ep isodes an d a chronic, downhill
course over years. Th e illn ess o ten stabilizes in m idli e.
2. Suicide is common in p atien ts with sch izop h ren ia. More th an 50% attem p t su icide (o ten
du rin g p ostp sych otic d ep ression or wh en h avin g h allu cin ation s “com m an din g” th em to
h arm th em selves), an d 10% o th ose d ie in th e attem p t.
3. Th e prognosis is better, an d th e su icide risk is lower i th e p atien t is old er at on set o illn ess,
is m arried, h as social relation sh ip s, is em ale, h as a good em p loym en t h istory, h as m ood
sym p tom s, h as ew n egative sym p tom s, an d h as ew relap ses.
Chapter 11 Schizophrenia Spectrum and Other Psychotic Disorders 113
E. Etiology. Wh ile th e etiology o sch izop h ren ia is n ot kn own , certain actors h ave been im p li-
cated in its d evelop m en t.
1. Genetic factors
a. Sch izop h ren ia occu rs in 1% of the population. Person s with a close gen etic relation sh ip
to a p atien t with sch izop h ren ia are m ore likely th an th ose with a m ore distan t relation -
sh ip to develop th e disord er (Tab le 11.2).
b. Certain chrom osom al m arkers have been associated with schizophren ia (see Chapter 4).
2. Other factors
a. Th e season of birth is related to th e occu rren ce o sch izop h ren ia. More p eop le with
sch izop h ren ia are born during cold weather months (i.e., Jan u ary to Ap ril in th e n orth ern
h em isp h ere an d Ju ly to Sep tem ber in th e sou th ern h em isp h ere). On e p ossible exp la-
n ation or th is in din g is viral infection of the mother du rin g p regn an cy, sin ce su ch in ec-
tion s occu r season ally.
b. No social or environmental factor causes schizophrenia. However, becau se p atien ts with
sch izop h ren ia ten d to d ri t down th e socioecon om ic scale as a resu lt o th eir social
de icits (th e “downward drift” hypothesis ), th ey are o ten ou n d in lower socioecon om ic
grou p s (e.g., h om eless p eop le).
F. Neural pathology
1. Anatomy
a. Abnormalities of the frontal lobes , as evid en ced by d ecreased u se o glu cose in th e ron -
tal lobes on p ositron em ission tom ograp h y (PET) scan s are seen in th e brain s o p eop le
with sch izop h ren ia.
b. Lateral and third ventricle enlargement, abn orm al cerebral sym m etry, an d ch an ges in
brain den sity also m ay be p resen t.
c. Decreased volume of limbic structures (e.g., am ygd ala, h ip p ocam p u s) is also seen .
2. Neurotransmitter abnormalities (see also Table 4.3)
a. Th e dopamine hypothesis o sch izop h ren ia states th at th e p ositive sym p tom s resu lt
rom excessive d op am in ergic activity (e.g., an excessive n u m ber o dop am in e recep -
tors, excessive con cen tration o d op am in e, h yp ersen sitivity o recep tors to dop am in e)
in th e lim bic system . As eviden ce or th is h yp oth esis, stim u lan t dru gs th at in crease
dop am in e availab ility (e.g., am p h etam in es an d cocain e) can cau se p sych otic sym p -
tom s (see Ch ap ter 9). Also, laboratory tests m ay sh ow elevated levels of homovanillic
acid (HVA), a m etabolite o dop am in e, in th e body lu ids o p atien ts with sch izop h re-
n ia. Th e n egative sym p tom s o sch izop h ren ia are b elieved to resu lt rom red u ced
d op am in ergic activity in th e ron tal cortex (see Ch ap ter 4).
b. Serotonin hyperactivity is im p licated in sch izop h ren ia becau se h allu cin ogen s th at
in crease seroton in con cen tration s cau se p sych otic sym p tom s, an d becau se som e
e ective an tip sych otics, su ch as clozap in e (see Ch ap ter 16), h ave an ti-seroton ergic-2A
(5-HT2A) activity.
c. Glutamate is im p licated in sch izop h ren ia; N-m eth yl- d -asp artate (NMDA) an tagon ists
(e.g., m em an tin e) are u se u l in treatin g som e o th e n eu rodegen erative sym p tom s
(e.g., loss o cogn itive abilities) in p atien ts with sch izoph ren ia.
G. Severity. Th e Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) n o
lon ger in cludes su btyp es o sch izop h ren ia bu t rath er distin gu ish es p atien ts by th e
severity o their sym p tom s (Table 11.3).
114 BRS Behavioral Science
Hallucinations Severe pressure to respond to auditory hallucinations (voices) or is very upset by the voices
Delusions Severe pressure to act upon the delusions (false beliefs) or is very upset by the false beliefs
Disorganized speech Speech is almost impossible to follow
Abnormal psychomotor Severe abnormal or bizarre motor behavior or almost constant catatonia (stupor with lack of
behavior coherent speech)
Negative symptoms Severe decrease in facial expressivity, gestures, or self-initiated behavior
H. Differential Diagnosis
1. Medical illnesses th at can cau se p sych otic sym p tom s, an d th us m im ic sch izoph ren ia (i.e.,
p sych otic disorder cau sed by a gen eral m edical con dition ), in clu de n eurologic in ection ,
n eoplasm , traum a, disease (e.g., Hun tin gton’s disease, m ultip le sclerosis), tem poral lobe
ep ilep sy, an d en docrin e disorders (e.g., Cu sh in g’s syn drom e, acute in term itten t p orp hyria).
2. Medications th at can cau se p sych otic sym p tom s in clu de an algesics, an tibiotics, an tich o-
lin ergics, an tih istam in es, an tin eop lastics, cardiac glycosides (e.g., digitalis), an d steroid
h orm on es.
3. Psychiatric illnesses oth er th an sch izop h ren ia th at m ay be associated with p sych otic
sym p tom s in clu de:
a. Oth er p sych otic d isord ers (see b elow).
b. Th e m an ic or dep ressive p h ase o bip olar I disorder, m ajor dep ressive disorder [see
Ch ap ter 12]).
c. Neu rocogn itive disord ers (e.g., deliriu m an d dem en tia [see Ch ap ter 14]).
d. Su bstan ce-related disorders (see Ch ap ter 9).
4. Schizotypal, paranoid, an d borderline personality disorders (see Ch ap ter 14) are n ot ch arac-
terized by ran k p sych otic sym p tom s bu t h ave oth er ch aracteristics o sch izop h ren ia (e.g.,
od d b eh avior, avoid an ce o social relation sh ip s).
I. Management
1. Pharmacologic management o sch izop h ren ia in clu des tradition al an tip sych otics (dop a-
m in e-2 [D 2]-recep tor an tagon ists) an d atyp ical an tip sych otic agen ts (see Ch ap ter 16).
Becau se o th eir better side e ect p ro iles, th e atyp ical agen ts are n ow irst-lin e treat-
m en ts. Lon g-actin g in jectab le “d ep ot” orm s (e.g., h alop erid ol d ecan oate) o an tip sy-
ch otics are u se u l op tion s in p atien ts wh ose sym p tom s or social circu m stan ces lead to
n on com p lian ce with m edication .
2. Psychological management, in clu d in g in d ividu al, am ily, an d grou p p sych oth erapy (see
Ch ap ter 17), is u se u l to provide long-term support an d to h elp th e p atien t adh ere to th e
d ru g regim en . Also, b ecau se o p overty an d related actors, th ese p atien ts o ten h ave lim -
ited access to n u trition al ood s an d so m ay develop nutritional deficiencies wh ich u rth er
exacerb ate th eir clin ical con d ition .
Schizophrenia Psychotic and residual symptoms Lifelong social and occupational impairment
lasting at least 6 mo
Brief psychotic disorder Psychotic symptoms lasting >1 d 50%–80% recover completely
but <1 mo; often precipitating
psychosocial factors
Schizophreniform Psychotic and residual symptoms 33% recover completely
disorder lasting 1–6 mo
Schizoaffective disorder Symptoms of depression or mania as Lifelong social and occupational impairment
well as schizophrenia; presence of (somewhat higher overall level of functioning
psychotic symptoms for at least 2 than in schizophrenia)
weeks without mood symptoms
Delusional disorder Fixed, persistent, delusional system 50% recover completely; many have relatively
(paranoid in the persecutory type normal social and occupational functioning
and romantic [often with a famous
person] in the erotomanic type);
few, if any, other thought disorders
Delusional disorder in Development of the same delusion in a 10%–40% recover completely when separated
partner of individual person in a close relationship (e.g., from the inducer
with delusional spouse, child) with someone with
disorder delusional disorder (the inducer)
17. A 45-year-old m an with a 20-year 20. A 40-year-old attorn ey is con vin ced th at
h istory o severe dep ression an d p sych otic h is wi e is tryin g to kill h im . Wh en h e locks
sym p tom s h as h eld di eren t jobs, bu t n on e h im sel in th e basem en t an d re u ses to com e
o them or m ore th an 6 m on th s. He is ou t, th e p olice are called an d h e is taken to
su ccess u lly treated or h is severe d ep ressive th e em ergen cy room o th e local h osp ital.
sym p tom s, bu t h e rem ain s with drawn an d Th e wi e, wh o den ies h er h u sb an d’s ch arge,
odd an d exp resses th e belie th at h e h as n otes th at th e p atien t h as been sh owin g
been “ch osen” or a sp ecial m ission on earth . in creasin gly stran ge beh avior over th e p ast
Medical evalu ation is u n rem arkab le. Wh at 9 m on th s. An abn orm al gait is observed on
is th e m ost ap p rop riate d iagn osis or th is p h ysical exam in ation . Th e h istory reveals
p atien t? th at th e p atien t’s m oth er an d u n cle, wh o
(A) Sch izop h ren ia h ad sh own sim ilar p sych iatric an d p h ysical
(B) Sch izoa ective d isorder sym p tom s, died in th eir early 50s a ter bein g
(C) Sch izop h ren i orm disorder in stitu tion alized in lon g-term care acilities
(D) Brie p sych otic d isord er or m an y years. Wh at is th e m ost ap p rop riate
(E) Delu sion al d isord er d iagn osis or th is p atien t?
(F) Delu sion al d isord er IPDD (A) Sch izop h ren ia
(G) Psych osis d u e to a gen eral m ed ical (B) Sch izoa ective disorder
con d ition (C) Sch izop h ren i orm disorder
(D) Brie p sych otic disorder
18. A 68-year-old p atien t tells th e p h ysician (E) Delu sion al d isord er
th at or th e last 7 years, h is n eigh bor h as (F) Delu sion al d isord er IPDD
been tryin g to get h im evicted rom h is (G) Psych osis du e to a gen eral m edical
ap artm en t by tellin g lies abou t h im to th e con d ition
lan dlord . Th e p atien t is m arried an d is
workin g u ll tim e in a job, wh ich h e h as 21. In a 50-year-old p atien t with
h eld or over 30 years. Medical evalu ation is sch izop h ren ia, th e size o th e cerebral
u n rem arkable. Wh at is th e m ost ap p rop riate ven tricles, glu cose u tilization in th e ron tal
diagn osis or th is p atien t? lobes, an d size o lim b ic stru ctu res are m ost
(A) Sch izop h ren ia likely to b e, resp ectively
(B) Sch izoa ective d isorder (A) in creased, decreased, decreased
(C) Sch izop h ren i orm disorder (B) in creased, decreased, in creased
(D) Brie p sych otic d isord er (C) in creased, in creased, decreased
(E) Delu sion al d isord er (D) decreased , decreased , d ecreased
(F) Delu sion al d isord er IPDD (E) decreased , in creased , decreased
(G) Psych osis d u e to a gen eral m ed ical (F) decreased , in creased , in creased
con d ition
22. Over th e p ast week, a 30-year-old
19. A 60-year-old wom an wh ose h u sban d em ale p atien t with sch izop h ren ia h as n ot
believes (in th e absen ce o an y eviden ce) sp oken alth ou gh sh e occasion ally m akes
th at th eir h ou se is f lled with rad ioactive du st odd squ awkin g sou n ds. Sh e sh ows alm ost
worries ab ou t h er ab ility to clear th e h ou se n o acial exp ression bu t seem s extrem ely
o the du st wh en h e is h osp italized. Medical agitated an d h olds u n com ortable-lookin g
evalu ation is u n rem arkable. Wh at is th e m ost b ody p osition s. At tim es, sh e ap p ears to be
ap prop riate diagn osis or th is wom an ? listen in g to som e u n seen p erson . On th e
(A) Sch izop h ren ia d im en sion s o severity scale, th is p atien t will
(B) Sch izoa ective d isorder h ave a score closest to
(C) Sch izop h ren i orm disorder (A) 0
(D) Brie p sych otic d isord er (B) 4
(E) Delu sion al d isord er (C) 10
(F) Delu sion al d isord er IPDD (D) 12
(G) Psych osis d u e to a gen eral m ed ical (E) 18
con d ition
An swers an d Exp lan ation s
1. The answer is D. Th is p atien t is sh owin g evid en ce o b rie p sych otic disord er. Th is
d isorder is ch aracterized by p sych otic sym p tom s lastin g >1 d ay, bu t <1 m on th ; sh e h as
h ad sym p tom s or th e p ast 2 weeks. Also, th e stress o ailin g th e exam is likely to b e a
p recip itatin g p sych osocial actor in th is p atien t. Sch izoa ective d isord er is ch aracterized
by sym p tom s o m an ia an d / or d ep ression an d sch izop h ren ia, as well as p sych otic
sym p tom s th at occu r even in th e ab sen ce o m ood sym p tom s, an d li elon g social an d
occu p ation al im p airm en t. In sch izop h ren ia, p sych otic an d resid u al sym p tom s last at least
6 m on th s, an d th ere is li elon g social an d occu p ation al im p airm en t. Sch izop h ren i orm
d isorder is ch aracterized by p sych otic an d residu al sym p tom s lastin g 1–6 m on th s. In
d elu sion al disorder, wh ich o ten lasts or years, th ere is a ixed , delu sion al system ; ew, i
an y, oth er th ou gh t d isord ers; an d relatively n orm al social an d occu p ation al u n ction in g.
In delu sion al d isord er IPDD, a p erson d evelop s th e sam e delu sion as a p erson with
d elu sion al disorder with wh om th ey are in a close relation sh ip. Psych osis du e to a gen eral
m ed ical con d ition in volves p sych otic sym p tom s occu rrin g as a resu lt o p h ysical illn ess.
2. The answer is D. Believin g th at you are b ein g p oison ed is a delu sion , th at is, a alse belie .
A h allu cin ation is a alse p ercep tion ; an illu sion is a m isp ercep tion o real extern al stim u li;
an id ea o re eren ce is th e alse b elie o b ein g re erred to by oth ers; an d a n eologism is a
n ew, in ven ted word . All o th ese p h en om en a can be seen in p atien ts exh ibitin g p sych otic
sym p tom s n o m atter wh at th e cau se.
3. The answer is A. An alysis o n eu rotran sm itter availability in th e lim bic system o th is
p atien t with a p ositive p sych otic sym p tom (e.g., a delu sion ) is m ost likely to reveal
in creased levels o dop am in e or seroton in . Acetylch olin e an d h istam in e are n ot so closely
in volved in th e p ath op h ysiology o p sych otic sym p tom s.
4. The answer is A. Th is p atien t wh o sh ows extrem e p sych om otor agitation an d u n u su al
u n com ortable-lookin g body p osition s is sh owin g cataton ia. Th e oth er listed sym p tom s
are n ot ch aracterized by p sych om otor agitation or h oldin g u n u su al body p osition s.
5. The answer is B. Th is p atien t’s b elie ab ou t th e govern m en t is a d elu sion . (see also an swer
to Qu estion 2).
6. The answer is B. A delusion is an exam ple o a disorder o thought content. Illusions and
hallucinations are disorders o perception, and loose associations and tangentiality are disorders
o orm o thought. Problem s with a ect are m ore likely to be seen in schizoa ective disorder.
7. The answer is A. Wh en com p ared to n egative sym p tom s (e.g., latten in g o a ect, p oor
sp eech con ten t, lack o m otivation , an d social with drawal), p ositive sym p tom s su ch as
delu sion s resp on d b etter to an tip sych otic m edication .
8. The answer is E. Social with d rawal is a n egative sym p tom o sch izop h ren ia. Negative
sym p tom s resp on d better to atyp ical an tip sych otic m edication th an to tradition al
119
120 BRS Behavioral Science
an tip sych otics. Hallu cin ation s, d elu sion s, agitation , an d overtalkativen ess are p ositive
sym p tom s o sch izop h ren ia.
9. The answer is A. An illusion is a m isperception o a real extern al stim ulus (e.g., a com puter
lookin g like a lion lurkin g in the corn er in a darken ed room ). A hallucin ation is a alse sen sory
p erception , an d a delusion is a alse belie n ot shared by others. An idea o re eren ce is the
alse belie o bein g re erred to by others, an d a n eologism is th e in ven tion o a n ew word.
10. The answer is E. An id ea o re eren ce is th e alse b elie o b ein g re erred to by oth ers (e.g., a
n ewscaster talkin g abou t th e p atien t on television ) (see also an swer to Qu estion 9).
11. The answer is D. Th is m an , wh o d resses stran gely, sh ows p oor groom in g, an d h as p aran oid
delu sion s an d au ditory h allu cin ation s over a p rolon ged p eriod, is m ost likely to h ave
sch izop h ren ia. Neu rop sych ological evalu ation o a p atien t with sch izop h ren ia is m ost
likely to reveal ron tal lobe d ys u n ction . Peop le with sch izop h ren ia u su ally sh ow in tact
m em ory; orien tation to p erson , p lace, an d tim e; an d relatively typ ical.
12. The answer is C. Th e ch an ce th at th e son (or oth er irst-d egree relative) o a p erson with
sch izop h ren ia will develop th e d isord er over th e cou rse o h is li e is ap p roxim ately 10%.
13. The answer is D. Th e ch an ce th at th e iden tical twin o a p erson with sch izop h ren ia will
develop th e d isord er over th e cou rse o h is or h er li e is ap p roxim ately 50%.
14. The answer is D. Ap p roxim ately 50% o p atien ts with sch izop h ren ia attem p t su icide at
som e p oin t in th eir lives.
15. The answer is E. Mood sym p tom s are associated with a good p rogn osis in sch izop h ren ia. A
good p rogn osis is also associated with old er age o on set, ew n egative sym p tom s, em ale
gen d er, an d ew relap ses.
16. The answer is C. Au d itory h allu cin ation s are th e m ost com m on typ e o h allu cin ation s seen
in sch izop h ren ia.
17. The answer is B. Th is p atien t is sh owin g eviden ce o sch izoa ective disorder. Th is
disord er is ch aracterized by sym p tom s o a m ood disorder, as well as p sych otic sym p tom s
(th e delu sion th at h e h as b een “ch osen”) as well as an d li elon g social an d occu p ation al
im p airm en t (see also an swer to Qu estion 1). Sch izoa ective disorder is distin gu ish ed
rom b ip olar an d m ajor d ep ressive d isorder in th at th e p sych otic sym p tom s p ersist in th e
absen ce o m ood sym p tom s.
18. The answer is E. This p atien t is sh owin g eviden ce o delu sion al disorder, p ersecutory typ e.
In this disorder, there is a ixed, delusion al system (paran oid in the persecutory type); ew, i
an y, oth er thought disorders; an d relatively n orm al social an d occupation al un ction in g (e.g.,
this p atien t is m arried an d has held a job or over 30 years) (see also an swer to Qu estion 1).
19. The answer is F. Th is p atien t is sh owin g eviden ce o delu sion al disorder IPDD. Sh e
h as develop ed th e sam e d elu sion th at h er h u sb an d h as (i.e., th eir h ou se is illed with
radioactive d u st). I sep arated or a p eriod o tim e rom h er h u sban d (th e in du cer), h er
p sych otic sym p tom s are likely to rem it (see also an swer to Qu estion 1).
20. The answer is G. Th is p atien t is sh owin g eviden ce o p sych osis du e to a gen eral m edical
con d ition . Th e abn orm al gait, age o th e p atien t, an d am ily h istory stron gly su ggest
Hu n tin gton’s d isease, wh ich o ten p resen ts with p sych iatric sym p tom s su ch as p sych osis
an d d ep ression (see also an swer to Qu estion 1).
21. The answer is A. In p atien ts with sch izop h ren ia, th e size o cerebral ven tricles, glu cose
u tilization in th e ron tal lobes, an d size o lim bic stru ctu res are m ost likely to be in creased,
decreased , an d decreased , resp ectively.
22. The answer is E. On th e d im en sion s o severity scale or sch izop h ren ia, th is p atien t will
h ave a score closest to 18. Sh e wou ld score 1 (equ ivocal) or delu sion s, 4 or h allu cin ation s
(listen in g to a n on existen t p erson ), 4 or disorgan ized sp eech (squ awkin g bu t n o clear
sp eech ), 4 or ab n orm al p sych om otor b eh avior (h oldin g odd p ostu res an d agitation ), an d
4 or n egative sym p tom s (n o acial exp ression or com m u n ication ).
Dep ressive Disorders
c ha pte r
12 an d Bip olar an d Related
Disorders
I. OVERVIEW
A. Definitions
1. Th e d ep ressive an d b ip olar d isord ers are ch aracterized by a p rim ary disturbance in inter-
nal emotional state (mood), cau sin g su bjective distress an d p roblem s in social an d occu p a-
tion al u n ction in g.
2. Given the patient’s current social and occupational situation, h e or sh e em otion ally eels:
a. Som ewh at worse th an wou ld be exp ected (dysthymia ).
b. Very m u ch worse th an wou ld b e exp ected (depression).
c. Som ewh at better th an wou ld be exp ected (hypomania ).
d. Very m u ch better th an wou ld b e exp ected (mania ).
3. Th e Diagn ostic an d Statistical Man u al of Men tal Disorders, Fifth Edition (DSM-5) sep arates
wh at were p reviou sly kn own as m ood disorders in to bip olar disorders (bip olar I, bip o-
lar II, an d cycloth ym ic disorders) an d dep ressive disorders (m ajor dep ressive disorder,
p ersisten t dep ressive disord er, an d p rem en stru al dysp h oric disorder [m arked a ective
lability associated with m en ses]). Th ese disorders are de in ed in p art by th e len gth o th eir
ep isod es as ollows:
a. Major depressive disorder: On e or m ore ep isod es o d ep ression , each con tin u in g or at
least 2 weeks .
121
122 BRS Behavioral Science
b. Bipolar disorder: Ep isodes o both m an ia (con tin u in g or at least 1 week) an d dep res-
sion (bipolar I disorder) or b oth h yp om an ia (con tin u in g or at least 4 days ) an d dep res-
sion (bipolar II disorder).
c. Persistent depressive disorder: Dysth ym ia or dep ression con tin u in g over a 2-year p eriod
(1 year in ch ild ren ) with n o discrete ep isodes o illn ess.
d. Cyclothymic disorder: Hyp om an ia an d d ysth ym ia occu rrin g over a 2-year p eriod (1 year
in ch ild ren ) with n o d iscrete ep isodes o illn ess.
e. Depressive and bipolar disorder due to another medical condition and substance/medi-
cation-induced depressive and bipolar disorder can be con sidered secon dary m ood
disord ers.
B. Epidemiology
1. Th ere are no differences in th e occu rren ce o dep ressive an d bip olar disorders associated
with eth n icity, ed u cation , m arital statu s, or in com e.
2. Lifetime prevalence o d ep ressive an d bip olar disorders
a. Major d ep ressive d isorder: 5%–12% or m en ; 10%–20% or wom en .
b. Bip olar d isord er: 1% overall; n o sex d i eren ce.
c. Persisten t d ep ressive disord er: 6% overall; u p to th ree tim es m ore com m on in wom en .
d. Cycloth ym ic d isord er: less th an 1% overall; n o sex di eren ce.
Elevated mood (has strong feelings of happiness and physical well-being) ++++
Grandiosity and expansiveness (has feelings of self-importance) ++++
Irritability and impulsivity (is easily bothered and quick to anger) ++++
Disinhibition (shows uncharacteristic lack of modesty in dress or behavior) ++++
Assaultiveness (cannot control aggressive impulses; causes legal problems) ++++
Distractibility (cannot concentrate on relevant stimuli) ++++
Flight of ideas (thoughts move rapidly from one to the other) ++++
Pressured speech (seems compelled to speak quickly) ++++
Impaired judgment (provides unusual responses to hypothetical questions [e.g., says she ++++
would buy a blood bank if she inherited money])
Psychotic symptoms (has delusions of power and influence) +++
Approximate percentage of patients in which the sign or symptom is seen: +, <25%; ++, 50%; +++, 70%; ++++, >70%.
5. Suicide risk
a. Patien ts with dep ressive an d b ip olar disorders an d oth er p sych ological p roblem s are
at in creased risk for suicide .
b. Certain dem ograp h ic, p sych osocial, an d p h ysical actors a ect th is risk (Table 12.2).
c. Th e top ive risk actors or su icid e rom h igh er to lower risk are:
(1) Seriou s p rior su icide attem p t.
(2) Age older th an 45 years.
(3) Alcoh ol d ep en den ce.
(4) History o rage an d violen t beh avior.
(5) Male sex.
B. Bipolar disorder
1. In bip olar disorder, th ere are ep isodes o both mania and depression (bipolar I disorder) or
both hypomania and depression (bipolar II disorder).
2. Th ere is n o sim p le m an ic d isord er becau se dep ressive sym p tom s even tu ally occu r.
Th ere ore, one episode of symptoms of mania (Table 12.1) alon e or h yp om an ia p lu s on e
ep isode o m ajor dep ression de in es bip olar disorder.
3. Psychotic symptoms , su ch as delu sion s, can occu r in dep ression (dep ression with p sy-
ch otic eatu res) as well as in m an ia.
a. In som e p atien ts (e.g., p oor p atien ts with low access to h ealth care), dep ressive or
bip olar d isord er with p sych otic sym p tom s can becom e severe en ou gh to be misdiag-
nosed as schizophrenia .
b. In con trast to sch izop h ren ia an d sch izoa ective disorder, in wh ich p atien ts are ch ron i-
cally im p aired , in d ep ressive an d bip olar disorders, th e p atien t’s m ood an d u n ction -
in g u su ally return to normal b etween ep isod es.
124 BRS Behavioral Science
C. Persistent depressive disorder (dysthymia) and cyclothymic disorder. In con trast to m ajor
dep ressive d isord er an d b ip olar disord er, resp ectively, p ersisten t dep ressive disorder an d
cycloth ym ic disorder are:
1. Non ep isodic.
2. Ch ron ic.
3. Rarely associated with p sych osis or su icid e.
III. ETIOLOGY
A. Th e biologic etiology o d ep ressive an d bip olar disorders in clu des:
1. Altered neurotransmitter activity (see Ch ap ter 4).
2. A genetic component, stron gest in bip olar disorder (Table 12.3).
3. Physical illness an d related actors (Tab le 12.4).
4. Abn orm alities o th e lim b ic–h yp oth alam ic–p itu itary–adren al axis (see Ch ap ter 5).
History Personal history Serious suicide attempt (about Suicidal gesture but not a serious
30% of people who attempt attempt
suicide try again and 10%
succeed)
<3 mo since previous attempt >3 mo since previous attempt
Possibility of rescue was remote Rescue was very likely
Family history Parent committed suicide No family history of suicide
Early loss of a parent through Intact family throughout childhood
divorce or death
Current, social, Psychiatric Depression Dysthymia or no depressive symptoms
psychological, symptoms Psychotic symptoms No psychotic symptoms
and physical Hopelessness Some hopefulness
factors Impulsiveness Thinks things out
Depth of Initial stages of recovery from The depth of severe depression;
depression deep depression; recovering patients rarely have the clarity of
patients may have enough thought or energy needed to plan
energy to commit suicide and commit suicide
Substance use Alcohol and drug dependence Little or no substance use
Current intoxication Good health
Physical health Serious medical illness (e.g., No recent visit to a physician
cancer, AIDS)
Perception of serious illness
(most patients have visited a
physician in the 6 mo prior to
suicide)
Social relationships Divorced (particularly men) Married
Widowed Strong social support
Single, never married Has children
Lives alone Lives with others
Demographic factors Age Elderly (persons aged 65 years Children (up to age 15 y)
and older, especially men) Young adults (age 25–40 y)
Middle aged (over age 55 y in
women and age 45 y in men)
Adolescents (suicide is the third
leading cause of death in
those 15–24 y of age; rates
increase after neighborhood
suicide of a teen or when
media depict teenage
suicide)
Chapter 12 Depressive Disorders and Bipolar and Related Disorders 125
Sex Male sex (men successfully Female sex (although women attempt
commit suicide three times suicide three times more often
more often than women) than men)
Occupation Professionals Nonprofessionals
Specific occupation Physicians (especially women
and psychiatrists)
Dentists and veterinarians
Police officers
Attorneys
Musicians
Unemployed Employed
Race Caucasian Non-Caucasian
Religion Not religious Religious
J ewish Catholic
Protestant Muslim
Economic Economic recession or Strong economy
conditions depression
Lethality of attempt Plan and means A plan for suicide (e.g., decision No plan for suicide
to stockpile pills)
A means of committing suicide No means of suicide
(e.g., access to a gun)
Sudden appearance of
peacefulness in an agitated,
depressed patient (he has
reached an internal decision
to kill himself and is now
calm)
Method Shooting oneself Taking pills or poison
Crashing one’s vehicle Slashing one’s wrists
Hanging oneself
J umping from a high place
General population 1
Person who has one parent or sibling (or dizygotic twin) with bipolar disorder 20
Person who has two parents with bipolar disorder 60
Monozygotic twin of a person with bipolar disorder 75
Cancer, particularly pancreatic and other gastrointestinal Schizophrenia (particularly after an acute psychotic
tumors episode)
Viral illness (e.g., pneumonia, influenza, acquired immune Adjustment disorder
deficiency syndrome [AIDS]) Anxiety disorder
Endocrinologic abnormality (e.g., hypothyroidism, diabetes, Normal reaction to a life loss, e.g., bereavement
Cushing’s syndrome) Somatic symptom disorder
Neurologic illness (e.g., Parkinson’s disease, multiple Eating disorder
sclerosis, Huntington’s disease, dementia, stroke Drug and alcohol use (particularly use of sedatives and
[particularly left frontal]) withdrawal from stimulants)
Nutritional deficiency (e.g., folic acid, B12) Prescription drug use (e.g., reserpine, steroids,
Renal or cardiopulmonary disease antihypertensives, antineoplastics)
126 BRS Behavioral Science
C. Psych osocial actors are not directly involved in the etiology of mania or h yp om an ia.
IV. MANAGEMENT
A. Overview
1. Dep ression is successfully managed in most patients .
2. On ly abou t 25% of patients with depression seek and receive treatment.
a. Patien ts d o n ot seek treatm en t in p art becau se Am erican s o ten b elieve th at m en tal
illn ess in dicates personal failure or weakness .
b. As in oth er illn esses, women are more likely than men to seek treatment.
3. Un treated ep isod es o d ep ression an d m an ia are usually self-limiting an d last ap p roxi-
m ately 6–12 m on th s an d 3 m on th s, resp ectively.
4. Th e most effective management o d ep ressive an d bip olar disorders is pharmacologic .
C. Psychological management
1. Psych ological m an agem en t or dep ression an d dysth ym ia in clu des p sych oan alytic, in ter-
p erson al, am ily, b eh avioral, an d cogn itive th erap ies (see Ch ap ter 17).
2. Psychological management in conjunction with medication is more effective th an eith er typ e
o m an agem en t alon e.
D. Electroconvulsive therapy (ECT) (see Ch ap ter 16). Th e p rim ary in d ication or ECT is major
depressive disorder. It is u sed wh en :
1. Th e sym p tom s do not respond to antidepressant medications .
2. An tidep ressan ts are too dangerous or have intolerable side effects . Th u s, ECT m ay be p ar-
ticu larly u se u l or elderly patients .
3. Rapid resolution o sym p tom s is n ecessary (e.g., th e p atien t is acu tely suicidal or psychotic ).
Review Test
1. A 65-year-old wom an , wh o was diagn osed 4. Th is college stu den t h as two broth ers.
with advan ced lu n g can cer 3 m on th s ago, Th e rst is h is m on ozygotic twin ; th e secon d
h as lost 18 p ou n ds, wakes requ en tly du rin g is 2 years you n ger. Th e risks th at h is rst
th e n igh t, an d h as very little en ergy. Over th e an d secon d broth ers will develop bip olar
p ast m on th , sh e h as been p reoccu p ied with disord er are, resp ectively, ab ou t
eelin gs o gu ilt abou t “p eop le I h ave h u rt in (A) 75% an d 60%
m y li e” an d exp resses con cern th at sh e will (B) 75% an d 20%
die in p ain . Th e sign or sym p tom m ost likely (C) 60% an d 10%
to in dicate th at th is p atien t is exp erien cin g (D) 50% an d 10%
a m ajor d ep ressive ep isode rath er th an a (E) 10% an d 1%
n orm al reaction to li e-lim itin g illn ess is
(A) weigh t loss
(B) decreased en ergy Questions 5 and 6
(C) di icu lty sleep in g
(D) p reoccu p ation with eelin gs o gu ilt For th e p ast ew m on th s, a 28-year-old wom an
(E) con cern ab ou t d yin g in p ain has seem ed ull o en ergy an d op tim ism or
n o obviou s reason . Alth ou gh sh e gets on ly
about 6 h ours o sleep a n igh t, sh e h as been
Questions 2–4 very p roductive at work. Sh e is talkative an d
gregariou s an d relates th at sh e belon gs to
A 20-year-old m ale college stu den t is taken to ou r clu b s an d two di eren t sp orts team s. A
the em ergen cy departm en t by p olice because ew years previously, rien ds say sh e was o ten
he tried to en ter a state o ice buildin g to “h ave pessim istic an d seem ed tired an d “wash ed
a con eren ce with th e govern or” abou t con - ou t.” Du rin g th at p eriod, sh e con tin u ed to
ductin g a un d drive to “ in an ce m y cu re or work but did n ot seek out social activities an d
can cer.” Wh en p olice p reven t h im rom en ter- had little in terest in sex. Th ere is n o eviden ce
in g the buildin g, he becom es irritable an d o a th ou gh t disorder an d th e p atien t den ies
hostile an d resists attem pts to restrain h im . su icidality or h op elessn ess. Ph ysical exam i-
n ation in clu din g body weigh t is n orm al.
2. Th e m ost ap p rop riate diagn osis or th is
p atien t is 5. Th is p atien t sh ows eviden ce o
(A) p ersisten t d ep ressive disorder (A) p ersisten t dep ressive disorder
(B) m ajor dep ressive d isord er (B) m ajor dep ressive disorder
(C) bip olar disord er (C) bip olar disord er
(D) illn ess an xiety disorder (D) illn ess an xiety disorder
(E) cycloth ym ic disord er (E) cycloth ym ic disorder
127
128 BRS Behavioral Science
16. A 15-year-old girl is brou gh t to th e 18. A 30-year-old n an cial con su ltan t tells
em ergen cy room a ter in gestin g 20 h er doctor th at over th e p ast 5 years sh e h as
acetam in op h en tablets. Sh e tells th e elt “d own” m ost o th e tim e. Sh e relates th at
p h ysician th at sh e tried to com m it su icide wh en colleagu es ask h er to din n er or to a
b ecau se sh e was n ot adm itted to an h on ors get-togeth er sh e u su ally says “yes” bu t th en
En glish class. Th e girl is th e p residen t o rarely eels like goin g wh en th e tim e com es
h er grade in sch ool an d always tries to an d does n ot h ave a good tim e wh en sh e
b e p er ect. Th e m ost im p ortan t actor in does go. Th ere are n o sign i can t p h ysical
wh eth er th is girl tries to kill h ersel again is n din gs. Wh ile th e p atien t den ies su icidality,
(A) th at sh e is em ale sh e n otes th at sh e n ever eels really excited
(B) th e m eth od o th e su icide attem p t or hap py abou t an yth in g. Th e best diagn osis
(C) th at sh e h as m ajor d ep ressive d isord er or th is p atien t at th is tim e is
(D) th at sh e tried to com m it su icide on ce (A) m ajor dep ressive disorder
(E) h er n eed to be p er ect (B) bip olar I d isorder
(C) bip olar II disorder
17. Wh en com p ared with a m an , th e ch an ces (D) p ersisten t dep ressive disorder
th at a wom an will develop m ajor d ep ressive (E) cycloth ym ic disorder
d isord er, p ersisten t d ep ressive d isorder, (F) su bstan ce-in du ced dep ressive disorder
or bip olar d isorder over th e cou rse o h er (G) dep ressive disorder du e to an oth er
li etim e are, resp ectively m ed ical con d ition
(A) h igh er, h igh er, equ al
19. A 45-year-old m an with bip olar disorder
(B) h igh er, h igh er, lower
tells h is d octor th at h e h as rem arried an d
(C) h igh er, equ al, h igh er
wou ld like to h ave a ch ild with h is n ew wi e.
(D) h igh er, h igh er, h igh er
He is con cern ed becau se th e 19-year-old
(E) equ al, h igh er, equ al
daugh ter th at h e h ad with h is rst wi e h as
(F) equ al, h igh er, lower
ju st been d iagn osed with b ip olar d isorder.
(G) equ al, equ al, equ al
Neith er o th e p atien t’s wives h as bip olar
disorder. Wh at is th e p robability th at th is
p atien t will h ave an oth er ch ild with bip olar
disorder?
(A) 1%
(B) 10%
(C) 20%
(D) 50%
(E) 70%
An swers an d Exp lan ation s
1. The answer is D. Th e sign or sym p tom m ost likely to in dicate that this p atien t is experien cin g
a m ajor dep ressive ep isode rath er than a n orm al reaction to serious illn ess is her
p reoccupation with eelin gs o guilt. Such eelin gs are m ore characteristic o depression than
sadn ess abou t bein g very ill. Th e oth er sym p tom s that the patien t sh ows (e.g., weight loss,
decreased en ergy, an d sleep p roblem s) are ch aracteristic o p atien ts with advan ced can cer.
Fear o dyin g in pain is realistic an d com m on ly seen in patien ts with li e-lim itin g illn esses.
2. The answer is C. 3. The answer is B. 4. The answer is B. Th is p atien t is m ost likely to h ave
bip olar I disord er. Wh ile th is disord er in volves ep isodes o both m an ia an d dep ression ,
a sin gle ep isod e o m an ia de in es th e illn ess. Th e belie s th at on e is im p ortan t en ou gh
to d em an d a con eren ce with th e govern or an d cu re can cer are gran diose d elu sion s.
Sch izop h ren ic delu sion s are com m on ly p aran oid in n atu re. Irritability an d h ostility are also
com m on in a m an ic ep isode. O th e listed treatm en ts, th e on e m ost e ective or bip olar
disorder is lith iu m . Heterocyclic an tid ep ressan ts, electrocon vu lsive th erapy, m on oam in e
oxidase in h ib itors, an d p sych oth erapy are u sed p rim arily to m an age dep ression .
An tid ep ressan ts an d p sych oth erapy are u sed to m an age dysth ym ia. Th e ch an ces o th e
m on ozygotic twin an d irst-d egree relative (e.g., broth er) o th is bip olar p atien t develop in g
th e d isord er are ab ou t 75% an d 20%, resp ectively.
5. The answer is E. 6. The answer is B. Th is p atien t sh ows eviden ce o cycloth ym ic disorder.
Th is d isord er in volves p eriods o b oth h yp om an ia (en ergy an d op tim ism ) an d dysth ym ia
(p essim ism an d eelin g “wash ed ou t”) occu rrin g over a 2-year p eriod with n o discrete
ep isodes o illn ess. O th e listed treatm en ts, th e on e m ost e ective or cycloth ym ic
disorder, as or b ip olar d isord er, is lith iu m . Heterocyclic an tidep ressan ts, electrocon vu lsive
th erapy, m on oam in e oxidase in h ibitors, an d p sych oth erapy are p rim arily u sed to m an age
dep ression . An tid ep ressan ts an d p sych oth erapy are u sed to m an age dysth ym ia.
7. The answer is E. 8. The answer is E. Th is wom an is showin g eviden ce o m ajor dep ression
(n ote: Su icidality is n ot ch aracteristic o a n orm al grie reaction ). Depressed p eop le typically
sh ow p oor groom in g. Sh e is also m ore likely to sh ow weight loss an d to eel better in the
even in g th an in th e m orn in g. Au ditory h allu cin ation s are com m on in schizop hren ia
bu t u n com m on in dep ression . Flight o ideas is characteristic o m an ia. An alysis o
n eurotran sm itter availability in th is p atien t is m ost likely to reveal decreased seroton in ,
com m on ly re lected in decreased plasm a levels o its m ajor m etabolite 5-HIAA. In creased
dopam ine is seen in schizophrenia, and decreased acetylcholine is seen in Alzheim er’s disease.
130
Chapter 12 Depressive Disorders and Bipolar and Related Disorders 131
I. ANXIETY DISORDERS
A. Fear and anxiety
1. Fear is a n orm al reaction to a kn own , extern al sou rce o dan ger.
2. In anxiety, th e in dividu al is righ ten ed bu t th e sou rce o th e dan ger is n ot kn own , n ot rec-
ogn ized, or inadequate to account for the symptoms .
3. Th e physiologic manifestations o an xiety are sim ilar to th ose o ear. Th ey in clu de:
a. Sh akin ess an d sweatin g.
b. Palp itation s (su b jective exp erien ce o tach ycardia).
c. Tin glin g in th e extrem ities an d n u m bn ess arou n d th e m ou th .
d. Dizzin ess an d syn cop e ( ain tin g).
e. Gastroin testin al an d u rin ary distu rban ces (e.g., diarrh ea an d u rin ary requ en cy).
f. Myd riasis (p u p il dilation )
132
Chapter 13 Anxiety Disorders, Somatic Symptom Disorders, and Related Conditions 133
In specific phobia, there is an irrational fear of certain things (e.g., elevators, snakes, or closed-in areas)
In social anxiety disorder, there is an exaggerated fear of embarrassment in social situations (e.g., public speaking, eating in
public, using public restrooms)
In agoraphobia, there is an intense fear associated with being in open places or situations in which one cannot escape or
obtain help
Because of the fear, the person avoids the object or situation
Avoidance leads to social and occupational impairment
Anxiety Disorders: Generalized Anxiety Disorder
Persistent anxiety symptoms including hyperarousal and worrying lasting 6 mos or more
Gastrointestinal symptoms are common
Symptoms are not related to a specific person or situation (i.e., free-floating anxiety)
Commonly starts during the 20s
Obsessive–Compulsive Disorder (OCD) and Related Disorders: Body Dysmorphic Disorder, Hoarding Disorder, and
Hair-Pulling Disorder (Trichotillomania)
Recurring, intrusive feelings, thoughts, and images (obsessions) that cause anxiety
Anxiety is relieved in part by performing repetitive actions (compulsions)
A common obsession is avoidance of hand contamination and a compulsive need to wash the hands after touching things
Obsessive doubts lead to compulsive checking (e.g., of gas jets on the stove) and counting of objects, obsessive need
for symmetry leads to compulsive ordering and arranging, and obsessive concern about discarding valuables leads to
compulsive hoarding (hoarding disorder: A distinct diagnosis in DSM-5)
Patients usually have insight (i.e., they realize that these thoughts and behaviors are irrational and want to eliminate them)
Usually start in early adulthood but may begin in childhood
OCD is increased in first-degree relatives of Tourette disorder patients and both disorders also involve the caudate nucleus
Body dysmorphic disorder involves excessive focus on a minor or imagined physical defect; the symptoms are not accounted
for by anorexia nervosa
Hair-pulling disorder involves a strong need to pull out one’s own hair. It may also involve hair eating which can result in
bezoars (hair balls) which can cause intestinal blockage
Trauma- and Stress-Related Disorders (Posttraumatic Stress Disorder [PTSD], Acute Stress Disorder [ASD], Adjustment
Disorder, Reactive Attachment Disorder, and Disinhibited Social Engagement Disorder)
Symptoms occurring after a catastrophic (life-threatening or potentially fatal event, e.g., war, house fire, serious accident,
rape, robbery) affecting the patient or the patient’s close relative or friend
Symptoms can be divided into four types:
(1) Reexperiencing (e.g., intrusive memories of the event [flashbacks] and nightmares)
(2) Hyperarousal (e.g., anxiety, increased startle response, impaired sleep, hypervigilance)
(3) Emotional numbing (e.g., difficulty connecting with others)
(4) Avoidance (e.g., survivor’s guilt, dissociation, and social withdrawal)
In PTSD, symptoms last for more than 1 mo (sometimes years) and may have a delayed onset
In ASD, symptoms last only between 2 d and 4 weeks
In adjustment disorder, there are emotional symptoms (e.g., anxiety, depression, or conduct problems) causing social, school,
or work impairment occurring within 3 mos and lasting less than 6 mos after a serious life event (e.g., divorce, bankruptcy,
changing residence) but do not meet full criteria for a mood or anxiety disorder
In adjustment disorder, symptoms can persist for more than 6 mos in the presence of a chronic stressor
Adjustment disorder is not diagnosed if the symptoms represent typical bereavement
Reactive attachment disorder and disinhibited social engagement disorder involve constellations of disturbances in social
relatedness due to abnormal rearing (e.g., being raised in an orphanage), see also Chapter 1
Chapter 13 Anxiety Disorders, Somatic Symptom Disorders, and Related Conditions 135
B. Differential diagnosis
1. Th e m ost im p ortan t di eren tial diagn osis o som atic sym p tom an d related disorders is
unidentified organic disease .
2. Factitiou s disorder (see below), m alin gerin g ( akin g or eign in g illn ess), an d m asked
dep ression (see Ch ap ter 12) also m u st be exclu ded .
C. Management
1. E ective strategies or m an agin g p atien ts with som atic sym p tom an d related disorders
in clu de:
a. Form in g a good physician–patient relationship (e.g., sch ed u lin g regu lar m on th ly
ap p oin tm en ts, p rovidin g reassu ran ce).
b. Providin g a multidisciplinary approach in clu din g oth er m edical p ro ession als (e.g., p ain
m an agem en t, m en tal h ealth services).
c. Iden ti yin g an d decreasing the social difficulties in th e p atien t’s li e th at m ay in ten si y
th e sym p tom s.
2. Antianxiety an d antidepressant agents, hypnosis , an d behavioral relaxation therapy also
m ay be u se u l.
Classification (Previous
DSM Terminology) Characteristics
Somatic symptom disorder One or more physical symptoms that disrupt daily life with excessive focus on the
symptoms
Being symptomatic for more than 6 mo
Illness anxiety disorder Exaggerated concern with health and illness lasting at least 6 mos in the absence of
somatic symptoms
Concern persists despite medical evaluation and reassurance
Care-seeking type goes to many different doctors seeking help (“doctor shopping”)
Conversion disorder Sudden, dramatic loss of sensory or motor function (e.g., blindness, paralysis), often
(functional neurological associated with a stressful life event
symptom disorder) Patients appear relatively unworried (“la belle indifférence”)
Somatic symptom disorder Intense acute or chronic pain not explained completely by physical disease and closely
with predominant pain associated with psychological stress
Onset usually in the 30s and 40s
136 BRS Behavioral Science
B. Feigned symptoms m ost com m on ly in clu d e abd om in al p ain , ever (by h eatin g th e th erm om -
eter), blood in th e u rin e (by ad din g b lood rom a n eedlestick), in du ction o tach ycardia (by
d ru g ad m in istration ), skin lesion s (by in ju rin g easily reach ed areas), an d seizu res.
137
138 BRS Behavioral Science
13. A 29-year-old m an exp erien ces su dd en asked abou t th is, h e says th at h e takes a
right-sided h em ip aresis b u t ap p ears lon g tim e b ecau se h e eels com p elled to
u n con cern ed. He rep orts th at ju st b e ore th e wash h im sel in a certain m an n er an d h as
on set o weakn ess, h e saw h is girl rien d with to rep eat th e wh ole p rocess i h e m akes a
an oth er m an . Ph ysical exam in ation ails to m istake. He kn ows th at th is beh avior sou n ds
reveal evid en ce o a m ed ical p roblem . ridicu lou s an d th at it m akes h im late or
sch ool an d oth er activities, bu t h e can n ot
14. A 41-year-old m an says th at h e h as been seem to stop h im sel rom doin g it. Th ere are
“sickly” or m ost o h is li e. He h as seen n o sign i can t m ed ical n din gs.
m an y doctors bu t is an gry with m ost o th em
b ecau se th ey u ltim ately re erred h im or 20. A 22-year-old m an is brou gh t in to
p sych ological h elp. He n ow ears th at h e h as th e em ergen cy room by th e p olice. Th e
stom ach can cer becau se h is stom ach m akes p olicem an tells th e p h ysician th at th e m an
n oises a ter h e eats. Ph ysical exam in ation is was cau gh t wh ile attem p tin g to rob a b an k.
u n rem arkable an d b ody weigh t is n orm al. Wh en th e p olice told h im to reeze an d drop
h is gu n , th e m an drop p ed to th e f oor an d
15. A 41-year-old m an says th at h e h as been could n ot sp eak, bu t rem ain ed con sciou s.
“sickly” or th e p ast 3 m on th s. He ears Wh en th e doctor attem p ts to in terview
th at h e h as stom ach can cer. Th e p atien t h im , th e p atien t rep eated ly alls asleep. Th e
is u n sh aven an d ap p ears th in an d slowed h istory reveals th at th e p atien t’s broth er h as
d own . Ph ysical exam in ation , in clu d in g a n arcolep sy. Wh ich o th e ollowin g best ts
gastroin testin al worku p, is u n rem arkab le th is clin ical p ictu re?
excep t th at th ere is an u n exp lain ed loss o (A) A sleep d isorder
15 p ou n ds sin ce h is last visit 1 year ago. (B) A seizu re disord er
(C) A som atic sym p tom disord er
16. A 28-year-old wom an seeks acial (D) Malin gerin g
recon stru ctive su rgery or h er “saggin g” (E) An en docrin e disord er
eyelid s. Sh e rarely goes ou t in th e d aytim e (F) A actitiou s disord er
b ecau se sh e b elieves th at th is ch aracteristic
m akes h er look “like a gran dm oth er.” On 21. A 12-year-old boy is adm itted to the
p h ysical exam in ation , h er eyelid s ap p ear h ospital with a diagn osis o “pain o un kn own
com p letely n orm al. origin .” His paren ts tell the physician th at
the child has com p lain ed about p ain in
17. A 29-year-old m an is u p set b ecau se h e h is legs or about 1 m on th. Neurologic an d
m u st take a clien t to din n er in a restau ran t. orthop edic exam in ation s ail to iden ti y an y
Althou gh h e kn ows th e clien t well, h e is so p athology. The history reveals that the child
a raid o m akin g a m ess wh ile eatin g th at h e was h ospitalized on two p revious occasion s
says h e is n ot h u n gry an d sip s rom a glass o or other pain sym p tom s or which n o cause
water in stead o orderin g a m eal. was oun d. A ter 4 days in the hosp ital, the
n urse reports that the ch ild sh ows little
18. A 29-year-old m an tells th e doctor th at eviden ce o pain an d seem s “rem arkably
h e h as b een so “n ervou s” an d u p set sin ce con ten t.” Sh e also rep orts th at sh e ou n d a
h is girl rien d broke u p with h im 1 m on th m edical textbook in the boy’s bedside table
ago th at h e h ad to qu it h is job an d stay at with a bookm ark in the section en titled
h om e. Th e m an h as n o h istory o m ed ical “skeletal pain o un kn own origin .” Which
or p sych iatric d isord ers, alth ou gh h is ath er o the ollowin g best describes sym ptom
h as a h istory o b ip olar d isord er, h is m oth er p roduction an d m otivation in th is case?
h as a h istory o alcoh olism , an d h is you n ger
(A) Sym p tom p rodu ction con sciou s,
b roth er was in reh ab or d ru g ad d iction th e
m otivation p rim arily con sciou s
p reviou s year.
(B) Sym p tom p rodu ction u n con sciou s,
m otivation p rim arily con sciou s
19. A 15-year-old b oy is b rou gh t to th e
(C) Sym p tom p rodu ction con sciou s,
d octor by h is m oth er or “stran ge b eh avior.”
m otivation p rim arily u n con sciou s
Sh e rep orts th at h er son is o ten late or
(D) Sym p tom p rodu ction u n con sciou s,
sch ool becau se h e sp en ds m ore th an an
m otivation p rim arily u n con sciou s
h ou r in th e sh ower every m orn in g. Wh en
140 BRS Behavioral Science
1. The answer is C. 2. The answer is A. 3. The answer is D. This patient is showin g eviden ce o pan ic
disorder with agoraphobia. Pan ic disorder is characterized by pan ic attacks, which in clude
in creased heart rate, dizzin ess, sweatin g, shortn ess o breath, an d ain tin g, an d the con viction
that one is about to die. This youn g wom an has also developed a ear o leavin g the house
(agoraphobia), which occurs in som e patien ts with pan ic disorder. While the m ost e ective
im m ediate treatm en t or this patien t is a ben zodiazepin e because it works quickly, the m ost
e ective lon g-term (m ain ten an ce) m an agem en t is an an tidepressan t, particularly a selective
seroton in reuptake in hibitor (SSRI) such as paroxetin e (Paxil). The n eural etiology m ost closely
in volved in pan ic disorder with agoraphobia is hypersen sitivity o the locus ceruleus.
4. The answer is B. Th is p atien t is m ost likely to h ave p osttrau m atic stress disorder (PTSD).
Th is d isorder, wh ich is ch aracterized by sym p tom s o an xiety an d in tru sive m em ories an d
n igh tm ares o a li e-th reaten in g even t su ch as rap e, can last or m an y years in ch ron ic orm
an d m ay h ave been in ten si ied in th is p atien t by reexp erien cin g h er own rap e th rou gh
th e rap e o h er coworker. Th e m ost e ective lon g-term m an agem en t or th is p atien t is a
su p p ort grou p, in th is case a rap e su rvivor’s grou p. Ph arm acologic treatm en t su ch as an
an tid ep ressan t is u se u l as an ad ju n ct to p sych ological m an agem en t in PTSD.
5. The answer is C. 6. The answer is D. Th is p atien t is m ost likely to have gen eralized an xiety
disorder (GAD). Th is disorder, wh ich in clu des ch ron ic an xiety an d, o ten , gastroin testin al
sym p tom s is m ore com m on in wom en an d o ten starts in th e 20s. Gen etic actors are seen in
th e observation th at oth er am ily m em bers have sim ilar p roblem s with an xiety. Addition al
sign s or sym p tom s o an xiety th at th is p atien t is likely to sh ow in clu de tin glin g in th e
extrem ities an d n u m bn ess arou n d th e m ou th , o ten resu ltin g rom h yp erven tilation . Fligh t
o ideas, h allu cin ation s, ideas o re eren ce, an d n eologism s are p sychotic sym p tom s, wh ich
are n ot seen in th e an xiety disorders or th e som atic sym p tom d isorders. O th e ch oices,
th e m ost e ective lon g-term m an agem en t or th is p atien t is busp iron e because, un like th e
ben zodiazep in es alp razolam an d diazep am , it d oes n ot cau se dep en den ce or with drawal
sym p tom s with lon g-term u se. Th e an tidep ressan ts ven la axin e an d du loxetin e an d SSRIs
also are e ective or lon g-term m an agem en t o GAD. Psychoth erapy an d β-blockers can be
u sed as adjun cts to treat GAD but are n ot th e m ost e ective lon g-term treatm en ts.
7. The answer is F. Th is p resen tation is an exam p le o m alin gerin g, eign in g illn ess or obviou s
gain (th e $30,000 workers’ com p en sation settlem en t). Evid en ce or th is is th at th e wom an
h as n o u rth er h an d p rob lem s a ter sh e receives th e m on ey. In con version disorder, som atic
sym p tom disorder, actitiou s d isord er, an d actitiou s disord er im p osed on an oth er, th ere is
n o obviou s or m aterial gain related to th e sym p tom s.
8. The answer is E. Robbery at kn i ep oin t, a li e-threaten in g even t, is m ost likely to result in
p osttrau m atic stress disorder (PTSD). Wh ile li e even ts such as divorce, ban krup tcy, illn ess,
an d ch an gin g residen ce are stress ul, th ey are rarely li e threaten in g. Psychological sym ptom s
occu rrin g a ter such less severe even ts m ay resu lt in adju stm en t disorder, n ot PTSD.
141
142 BRS Behavioral Science
9. The answer is C. 10. The answer is D. Th is p resen tation is an exam p le o actitiou s disorder
im p osed on an oth er. Th e m oth er h as eign ed th e ch ild’s illn ess (ep isodes o breath in g
p roblem s an d abdom in al p ain ) or atten tion rom m edical p erson n el. Th is akin g h as
resu lted in ou r abdom in al su rgical procedu res in wh ich n o abn orm alities were ou n d.
Sin ce sh e kn ows sh e is lyin g, th e m oth er will becom e an gry an d lee wh en con ron ted
with th e tru th . Th e irst th in g th e p h ysician m u st do is to n oti y th e state social service
agen cy sin ce actitiou s d isorder im p osed on an oth er is a orm o ch ild ab u se. Waitin g u n til
th e ch ild’s n ext visit be ore actin g cou ld resu lt in th e ch ild’s u rth er in ju ry or even death .
Callin g in sp ecialists m ay b e ap p rop riate a ter th e p h ysician rep orts h is su sp icion s to
th e state. It is n ot ap p rop riate to take th e ch ild aside an d ask h im h ow h e really eels. He
p robably is n ot aware o h is m oth er’s beh avior.
11. The answer is E. Th is wom an with a 20-year h istory o u n exp lain ed vagu e an d ch ron ic
p h ysical com p lain ts p rob ab ly h as som atic sym p tom d isorder. Th is can be d istin gu ish ed
rom illn ess an xiety d isorder, wh ich is an exaggerated worry abou t n orm al p h ysical
sen sation s an d m in or ailm en ts (see also an swers to Qu estion s 12–18).
12. The answer is K. Th is teen ager, wh o was orm erly ou tgoin g an d a good stu den t an d n ow
seem s sad, loses in terest in m akin g rien ds, an d b egin s to do p oor work in sch ool, p rob ably
h as adju stm en t disorder (with dep ressed m ood). It is likely th at h e is h avin g p roblem s
adju stin g to h is n ew sch ool. In con trast to ad ju stm en t d isord er, in m asked dep ression ,
th e sym p tom s are m ore severe an d o ten in clu de sign i ican t weigh t loss or su icidality (see
Ch ap ter 12).
13. The answer is H. Th is m an , wh o exp erien ces a su dd en n eu rological sym p tom triggered by
seein g h is girl rien d with an oth er m an , is sh owin g eviden ce o con version disorder. Th is
disord er is ch aracterized by an ap p aren t lack o con cern abou t th e sym p tom s (i.e., “la b elle
in di éren ce”).
14. The answer is B. Th is m an , wh o says th at h e h as b een “sickly” or m ost o h is li e an d ears
th at h e h as stom ach can cer, is sh owin g eviden ce o illn ess an xiety disorder exaggerated
con cern over n orm al p h ysical sen sation s (e.g., stom ach n oises) an d m in or ailm en ts. Th ere
are n o p h ysical in d in gs n or obviou s evid en ce o d ep ression in th is p atien t.
15. The answer is L. Th is m an p rob ably h as m asked d ep ression . In con trast to th e m an with
illn ess an xiety d isord er in th e p reviou s qu estion , evid en ce or d ep ression in th is p atien t
in clu des th e act th at, in ad d ition to th e som atic com p lain ts, h e sh ows sym p tom s o
d ep ression (e.g., h e is n ot groom ed , ap p ears slowed down [p sych om otor retardation ], an d
h as lost a sign i ican t am ou n t o weigh t).
16. The answer is G. Th is wom an p robably h as b od y d ysm orp h ic d isord er, wh ich is
ch aracterized by overcon cern ab ou t a p h ysical eatu re (e.g., “saggin g” eyelids in th is case),
desp ite n orm al ap p earan ce.
17. The answer is J . Th is m an p robab ly h as social an xiety disord er. He is a raid o
em barrassin g h im sel in a p u blic situ ation (e.g., gettin g ood on h is ace wh ile eatin g
d in n er in ron t o oth ers in a restau ran t).
18. The answer is K. Th e m ost likely exp lan ation or th is clin ical p ictu re th at in clu d es
sym p tom s o an xiety th at begin a ter a li e stressor (e.g., a rom an tic break-u p ) is
adju stm en t disord er (with an xiety). Th e ab sen ce o a p reviou s h istory an d th e b rie
du ration in d icates th at th is is n ot an an xiety d isord er, an d th e act th at th e stressor was n ot
li e-th reaten in g ru les ou t PTSD an d ASD. Th e am ily h istory is n ot likely to be related to
th is p atien t’s sym p tom s in th is case.
19. The answer is C. Th is 15-year-old wh o m u st wash h im sel in a certain m an n er each day
is sh owin g eviden ce o OCD. OCD is a d isord er in wh ich on e is com p elled to en gage in
rep etitive n on p rodu ctive b eh avior th at, as in th is p atien t, im p airs u n ction (e.g., th e
p atien t is late or sch ool an d activities). Th e act th at th is teen ager h as in sigh t, th at is, h e
kn ows th at wh at h e is d oin g is “rid icu lou s,” also is ch aracteristic o OCD.
Chapter 13 Anxiety Disorders, Somatic Symptom Disorders, and Related Conditions 143
20. The answer is D. Wh en th ere is in an cial or oth er obviou s gain to be obtain ed rom an
illn ess, th e p ossibility th at th e p erson is m alin gerin g m u st be con sidered. In th is case, a
m an wh o h as com m itted a crim e is eign in g sym p tom s o n arcolep sy to avoid p rosecu tion .
Kn owledge o th e details o h is broth er’s illn ess h as tau gh t h im h ow to eign th e catap lexy
(su d den loss o m otor con trol) an d d aytim e sleep in ess associated with n arcolep sy (see
Ch ap ter 7).
21. The answer is C. Th is clin ical p resen tation is an exam p le o actitiou s d isord er (n ote: Most
p sych iatric d iagn oses d isorders can also be m ade in ch ildren ). In con trast to p atien ts with
som atic sym p tom disorders wh o really believe th at th ey are ill, p atien ts with actitiou s
disord er are con sciou s o th e act th at th ey are eign in g th eir illn ess. Pain is on e o th e m ost
com m on ly eign ed sym p tom s, an d th is p atien t’s n igh ttim e readin g is p rovidin g h im with
sp eci ic kn owled ge o h ow to eign th e sym p tom s realistically. Alth ou gh h e is con sciou sly
p rodu cin g h is sym p tom s, th is boy is n ot receivin g tan gible ben e it or h is beh avior. Th u s,
in con trast to in dividu als wh o are con sciou sly eign in g illn ess or obviou s gain , th at is,
m alin gerin g (see also an swer to Qu estion 20), th e m otivation or th is p atien t’s p ain - akin g
beh avior is p rim arily u n con sciou s.
22. The answer is A. Th is m an’s rep eated ch eckin g an d cou n tin g beh avior in dicates th at
h e h as OCD. Th e m ost e ective lon g-term m an agem en t or OCD is an an tidep ressan t,
p articu larly a selective seroton in reu p take in h ibitor (SSRI) su ch as lu voxam in e (Lu vox) or
a h eterocyclic agen t su ch as clom ip ram in e. An tian xiety agen ts su ch as ben zodiazep in es
(e.g., diazep am ) an d bu sp iron e an d β-b lockers su ch as p rop ran olol are m ore com m on ly
u sed or th e m an agem en t o acu te or ch ron ic an xiety. An tip sych otic agen ts su ch as
h alop eridol m ay be u se u l as adju n cts bu t do n ot su bstitu te or SSRIs or clom ip ram in e in
OCD.
23. The answer is C. Th e n eed to ch eck an d rech eck th e ch ild’s p ortion s an d rep eatedly take
h im to th e doctor in dicates th at, as in Qu estion 22, th is p atien t is sh owin g sym p tom s o
OCD. Th e act th at sh e kn ows th at h er b eh avior is excessive (“in sigh t”) is typ ical o p atien ts
with OCD. As n oted in An swer 22, th e m ost e ective lon g-term m an agem en t or OCD is an
SSRI or a cyclic an tid ep ressan t su ch as clom ip ram in e.
24. The answer is F. Th e triad o h yp oglycem ia, very h igh in su lin level, an d su p p ressed
p lasm a C p ep tide in d icate th at th is n u rse h as sel -adm in istered in su lin , a situ ation kn own
as actitiou s h yp erin su lin ism . In h yp erin su lin ism du e to m edical cau ses, or exam p le,
in su lin om a (p an creatic β-cell tu m or), p lasm a C p ep tide is typ ically in creased, n ot
d ecreased . Factitiou s d isord er is m ore com m on in p eop le, like th is wom an , associated
with th e h ealth p ro ession s. Th ere is n o eviden ce in th is wom an o a sleep disorder, an xiety
d isord er, som atic sym p tom d isorder, or en docrin e disorder su ch as diabetes. Becau se th ere
is n o obviou s or p ractical gain or th is wom an in bein g ill, m alin gerin g is u n likely.
25. The answer is A. Like th e wom an in th e p reviou s qu estion , th is h ealth y m an is sh owin g
evid en ce o actitiou s d isord er. Peop le with actitiou s disorder p u rp osely eign illn ess
(in con trast to con version d isord er an d som atic sym p tom disorder in wh ich sym p tom
p rodu ction is u n con sciou s) in order to be con sidered a sick p erson by oth ers (see also
an swer to Qu estion 21). Th ere is n o tan gib le gain to be ob tain ed rom assu m in g th e “sick
role” as th ere is in m alin gerin g. Th ere is n o eviden ce o a sp eci ic li e stressor in itiatin g
p sych ological sym p tom s as th ere wou ld be in adju stm en t disorder.
Neu rocogn itive,
c ha pte r
14 Person ality, Dissociative,
an d Eatin g Disorders
I. NEUROCOGNITIVE DISORDERS
A. General characteristics
1. Neu rocogn itive disord ers (NCDs) in volve p roblem s in memory, orien tation , level o con-
sciousness , an d oth er in tellectu al u n ction s.
a. Th ese di icu lties are du e to abn orm alities in n eu ral ch em istry, stru ctu re, or p h ysiol-
ogy originating in the brain or secondary to systemic illness .
b. Patien ts with NCDs m ay also sh ow psychiatric symptoms (e.g., dep ression , an xiety,
h allu cin ation s, delu sion s, an d illu sion s; see Table 8.2), wh ich are secon dary to th e n eu -
rocogn itive p rob lem s.
c. Th e NCDs in clu de:
(1) Delirium.
(2) Major and mild NCD (dementia) du e to Alzheimer’s disease , ron totem p oral lobar
degen eration , Lewy b ody disease, vascu lar disease, trau m atic brain in ju ry, su b-
stan ce/ m edication -in d u ced, HIV in ection , p rion disease (e.g., Creu tz eld t-Jakob
disease), Parkin son’s d isease, or Hu n tin gton’s d isease.
(3) NCD due to another medical condition or multiple etiologies.
2. Ch aracteristics an d etiologies o m an y o th ese disorders can be ou n d in Table 14.1 an d
below.
144
Chapter 14 Neurocognitive, Personality, Dissociative, and Eating Disorders 145
Hallmark Impaired consciousness Loss of memory and Loss of memory with few other
intellectual abilities cognitive problems
Etiology CNS disease (e.g., Huntington’s Alzheimer’s disease Thiamine deficiency due to long-term
or Parkinson’s disease) Vascular disease alcohol use, leading to destruction
of mediotemporal lobe structures
(e.g., mammillary bodies)
CNS trauma CNS trauma Temporal lobe trauma, vascular
disease, or infection (e.g., herpes
simplex encephalitis)
CNS infection (e.g., meningitis, CNS infection (e.g., HIV or
HIV) Creutzfeldt-J akob
Systemic disease (e.g., hepatic, disease)
cardiovascular) NCD with Lewy bodies
High fever Pick’s disease
Substance use (frontotemporal
Substance withdrawal dementia)
Prescription drug overdose
(e.g., atropine)
Occurrence More common in children and More common in the More common in patients with a
the elderly elderly history of alcohol use
Most common etiology of Seen in about 20% of those
psychiatric symptoms in over age 85
medical and surgical hospital
units
Associated physical Acute medical illness No medical illness No medical illness
findings Autonomic dysfunction Little autonomic Little autonomic dysfunction
Abnormal EEG (fast wave dysfunction Normal EEG
activity or generalized Normal EEG
slowing)
Associated Impaired consciousness Normal consciousness Normal consciousness
psychological Illusions, delusions (often Psychotic symptoms Psychotic symptoms uncommon
findings paranoid) or hallucinations uncommon in early in early stages
(often visual and stages Depressed mood
disorganized) Depressed mood Little diurnal variability
“Sundowning” (symptoms much “Sundowning” Confabulation (untruths told to hide
worse at night) Personality changes memory loss)
Anxiety with psychomotor in early stages (in
agitation frontotemporal NCD)
Course Develops quickly Develops slowly Develops slowly
Fluctuating course with lucid Progressive downhill Progressive downhill course if
intervals course alcohol use continues
Management and Removal of the underlying No effective treatment, No effective treatment, rarely
prognosis medical problem will allow rarely reversible reversible
the symptoms to resolve Pharmacotherapy and Pharmacotherapy and supportive
Provide a structured supportive therapy therapy to manage associated
environment to treat associated psychiatric symptoms
Increase orienting stimuli psychiatric symptoms Vitamin B1 for acute symptoms if
Delirium must be ruled out Acetylcholinesterase due to alcohol use
before dementia can be inhibitors and NMDA
diagnosed receptor antagonists
(for Alzheimer’s disease)
Antihypertensive or
anticlotting agent (for
vascular disease)
Provide a structured
environment
CNS, central nervous system; HIV, human immunodeficiency virus; EEG, electroencephalogram; NMDA, N-methyl-d -aspartate.
146 BRS Behavioral Science
B. Delirium
1. Deliriu m is a syn d rom e th at in clu d es confusion an d clouding of consciousness th at resu lt
rom cen tral n ervou s system im p airm en t.
2. It u su ally occu rs in th e cou rse o an acute medical illness su ch as en cep h alitis or m en in -
gitis bu t is also seen in dru g u se an d with drawal, p articu larly with drawal rom alcoh ol
(“deliriu m trem en s”).
3. It is com m on in surgical and coronary intensive care u n its an d in elderly debilitated patients .
D. Alzheimer’s disease
1. Diagnosis
a. Patien ts with Alzh eim er’s d isease sh ow a gradual loss of memory and intellectual abili-
ties . Th eir p sych iatric sym p tom s in clu d e in ability to con trol im p u lses an d lack o ju dg-
m en t as well as d ep ression an d an xiety.
b. Later in th e illn ess, sym p tom s in clu d e con u sion an d p sych osis th at p rogress to com a
an d death (usually within 8–10 years of diagnosis).
c. For p atien t m an agem en t an d progn osis, it is im p ortan t to m ake th e distin ction between
Alzheimer’s disease an d b oth pseudodementia (dep ression th at m im ics dem en tia) an d
beh avioral ch an ges associated with normal aging (Table 14.2).
2. Genetic associations in Alzh eim er’s d isease in clu d e:
a. Abn orm alities o chromosome 21 (Down’s syn drom e p atien ts u ltim ately develop
Alzh eim er’s disease).
b. Abn orm alities o chromosomes 1 and 14 (sites o th e p resen ilin 2 an d p resen ilin 1 gen es,
resp ectively) im p licated p articu larly in early onset Alzh eim er’s d isease (i.e., occu rrin g
b e ore th e age o 65).
c. Possession o at least on e copy o th e ap olip op rotein E4 (apoE4) gen e on chrom osom e 19.
d. Gen d er—th ere is a h igh er occu rren ce o Alzh eim er’s disease in women.
Alzheimer’s Brain A 65-y-old former banker Severe memory loss Structured environment
disease dysfunction cannot remember to turn Other cognitive problems Acetylcholinesterase
off the gas jets on the Decrease in IQ inhibitors
stove nor can he name Disruption of normal life NMDA receptor
the object in his hand antagonists
(a comb) Ultimately, nursing home
placement
Pseudodementia Depression of A 65-y-old dentist cannot Moderate memory loss Antidepressants
(depression mood remember to pay her Other cognitive problems Electroconvulsive therapy
that mimics bills. She also appears No decrease in IQ (ECT)
dementia) to be physically “slowed Disruption of normal life Psychotherapy
down” (psychomotor
retardation) and very sad
Normal aging Minor changes A 65-y-old woman forgets Minor forgetfulness No medical intervention
in the normal new phone numbers and Reduction in the ability Practical and emotional
aging brain names but functions well to learn new things support from the
living on her own quickly physician
No decrease in IQ
No disruption of normal life
Chapter 14 Neurocognitive, Personality, Dissociative, and Eating Disorders 147
B. Classification
1. PDs are categorized by th e Diagn ostic an d Statistical Man u al of Men tal Disorders, Fifth
Edition (DSM-5) in to clusters: A (p aran oid , sch izoid , sch izotyp al); B (h istrion ic, n arcissis-
tic, borderlin e, an d an tisocial); an d C (avoidan t, obsessive-com p u lsive, an d dep en den t).
Oth er categories are p erson ality ch an ge du e to an oth er m edical con dition , oth er sp eci-
ied PD, an d u n sp eci ied PD. Th e category oth er sp eci ied PD is u sed wh en several PDs are
p resen t bu t n on e reach criteria or a sp eci ic PD; u n sp eci ied PD is u sed wh en th e p erson
h as a PD b u t it is n ot in clu ded in an y o th e th ree clu sters (e.g., p assive–aggressive PD).
2. Each cluster has its own hallm ark characteristics an d genetic or fam ilial associations (e.g.,
relatives o people with PDs have a higher likelihood o having certain disorders) (Table 14.3).
3. PDs are typ ically irst ob servable d u rin g adolescen ce an d m u st be p resen t by early
adu lth ood . An tisocial PD can n ot b e d iagn osed u n til th e age o 18; p rior to th is age, th e
d iagn osis is con d u ct disord er (see Ch ap ter 15).
Cluster A
Hallmark Avoids social relationships and is “peculiar” but not psychotic
Genetic or familial association Psychotic illnesses
Paranoid Distrustful, suspicious, litigious
Attributes responsibility for own problems to others
Interprets motives of others as malevolent
Collects guns
Schizoid Long-standing pattern of voluntary social withdrawal
Detached, restricted emotions, lacks empathy, has no thought disorder
Schizotypal Peculiar appearance
Magical thinking (i.e., believing that one’s thoughts can affect the course of events)
Odd thought patterns and behavior without frank psychosis
Cluster B
Hallmark Dramatic, emotional, inconsistent
Genetic or familial association Depressive, bipolar, substance use, and somatic symptom disorders
Histrionic Theatrical, extroverted, emotional, sexually provocative, “life of the party”
Shallow, vain
In men, “Don J uan” dress and behavior
Cannot maintain intimate relationships
Chapter 14 Neurocognitive, Personality, Dissociative, and Eating Disorders 149
C. Management
1. For th ose wh o seek h elp, in divid u al an d grou p p sych oth erapy m ay be u se u l.
2. Ph arm acoth erapy also can be u sed to m an age sym p tom s su ch as dep ression an d an xiety
th at m ay be associated with th e PDs.
Classification Characteristics
Dissociative amnesia with or without Failure to remember important information about oneself after a stressful life
dissociative fugue event
Amnesia usually resolves in minutes or days but may last years
Fugue involves amnesia combined with sudden wandering from home after a
stressful life event
Fugue may also involve adoption of a different identity
Dissociative identity disorder (formerly At least two distinct personalities (“alters”) in an individual
multiple personality disorder) More common in women (particularly those sexually abused in childhood)
In a forensic (e.g., jail) setting, malingering and alcohol use must be considered
and excluded
Depersonalization/derealization Recurrent, persistent feelings of detachment from one’s own body, the social
disorder situation (depersonalization), or the environment (derealization) when
stressed
Understanding that these perceptions are only feelings, that is, normal reality
testing
Identity disruption Dissociative symptom (e.g., trance-like state, memory loss) (1) in persons
exposed to intense coercive persuasion (e.g., brainwashing) or (2) indigenous
to particular locations or cultures (e.g., “Amok” in Indonesia)
WEIGHT HEIGHT
kg lb BODY cm in.
340
150
320
MAS S
140 INDEX 125
300 50
130 280 [WT/(HT)2 ] 130
120 70
260
110 240 60 135
100 220 55
50 140
95
90 200 Morbid obe s ity
85 190 40 (BMI ≥ 40) 145
80 180
170 150
75
160 60
70
150 Ove rwe ight 30 Obe s e 155
65 (BMI 25–29.9) (BMI ≥ 30)
140
160
55 130 Norma l we ight
55 120 (BMI 20.0–24.9) 20 165 65
Anorexia nervosa Extreme weight loss (BMI Refusal to eat despite normal Hospitalization directed at
< 17.0) appetite because of an reinstating nutritional
Electrolyte disturbances overwhelming fear of being obese condition (starvation and
Hypercholesterolemia Belief that one is fat when very thin compensatory behavior
Mild anemia and leukopenia High interest in food-related such as purging can result
Lanugo (downy body hair on activities (e.g., cooking) in metabolic abnormalities
the trunk) Simulates eating [e.g., hypokalemia] leading
Melanosis coli (darkened Lack of interest in sex to cardiac arrhythmia
area of the colon if there is Was a “perfect child” (e.g., good causing death)
laxative abuse) student) Family therapy (aimed
Osteoporosis Interfamily conflicts (e.g., patient’s particularly at normalizing
Cold intolerance problem draws attention away the mother–child
Syncope from parental marital problem relationship)
or an attempt to gain control to Group psychotherapy in an
separate from the mother) inpatient eating disorders
Excessive exercising program
(“hypergymnasia”)
Bulimia nervosa Relatively normal body weight Binge-eating (in secret) of Cognitive and behavioral
Esophageal varices caused by high-calorie foods, followed therapies
repeated vomiting by vomiting or other purging Average to high doses of
Tooth enamel erosion due to behavior to avoid weight gain antidepressants; fluoxetine
gastric acid in the mouth Depression is the only FDA-approved
Swelling or infection of the “Hypergymnasia” agent; bupropion is
parotid glands contraindicated because it
Metacarpal–phalangeal lowers seizure threshold
calluses (Russell’s sign) from Group psychotherapy in an
the teeth because the hand inpatient or outpatient
is used to induce gagging eating disorders program
Electrolyte disturbances
Review Test
153
154 BRS Behavioral Science
Questions 16 and 17
20. A 75-year-old m an with a 5-year h istory 22. A 20-year-old em ale college stu den t tells
o Alzh eim er’s disease h as recen tly becom e th e doctor th at b ecau se sh e was a raid to
disorien ted wh en th e ligh ts are tu rn ed o b e alon e, sh e tried to com m it su icide a ter a
at n igh t. He wan ders abou t th e ap artm en t m an with wh om sh e h ad two dates did n ot
at n igh t an d h is wi e is con cern ed th at h e call h er again . A ter th e in terview, sh e tells
will in ju re h im sel wh ile sh e is sleep in g. Th e h im th at all o th e oth er doctors sh e h as seen
Folstein Min i–Men tal State Exam sh ows th at were terrible an d th at h e is th e on ly doctor
th e p atien t is d isorien ted regard in g tim e wh o h as ever u n derstood h er p roblem s.
an d p lace an d h as p oor sh ort-term m em ory.
Ph ysical exam in ation is u n rem arkab le 23. Wh en ever a 28-year-old wom an
an d th e p atien t is n ot cu rren tly takin g an y p resen ts to th e d octor’s o ce, sh e b rin gs
m edication . Wh at is th e m ost ap p rop riate gi ts or th e recep tion ist an d th e n u rses.
rst recom m en d ation or th e m an agem en t Wh en sh e h ears th at on e o th e n u rses h as
o this p atien t? taken an oth er job, sh e b egin s to sob lou d ly.
(A) Ask th e wi e to in crease h om e n igh ttim e Wh en th e d octor sees h er, sh e rep orts th at
ligh tin g. sh e is so warm th at sh e m u st h ave “a ever
(B) Prescrib e don ep ezil or th e p atien t. o at least 106°F.”
(C) Prescrib e h alop eridol or th e p atien t.
(D) Prescrib e m eth ylp h en idate or th e wi e 24. Two weeks a ter a 50-year-old, overweigh t,
so th at sh e can stay alert d u rin g th e h yperten sive wom an agreed to start an
n igh t. exercise program , she gain ed 4 poun ds. She
(E) Recom m en d th at th e p atien t b e p u t in rep orts th at she h as n ot exercised yet becau se
m ech an ical restrain ts at bed tim e. “th e gym was too crowded.”
1. The answer is B. Th is clin ical p ictu re th at in clu des th e su dden on set o a p sych iatric
sym p tom (i.e., visu al h allu cin ation s) coin cidin g with th e on set o a h igh ever in a relatively
recen tly d iagn osed (1 year) AIDS p atien t is m ost con sisten t with deliriu m cau sed by an
op p ortu n istic in ection o th e brain su ch as cryp tococcal m en in gitis. Psych otic illn esses
su ch as sch izop h ren ia, b rie p sych otic d isorder, or AIDS dem en tia can n ot be diagn osed i
th e sym p tom s (as in th is p atien t) can be exp lain ed by an acu te m edical illn ess. Also, AIDS
d em en tia occu rs in th e late stages o th e d isease an d wou ld be ch aracterized p rim arily by
grad u ally worsen in g cogn itive u n ction in g (e.g., m em ory loss) as well as m otor sym p tom s.
Neu rocogn itive disord er du e to an oth er m edical con dition is o ten associated with a h istory
o alcoh olism an d h as a gradu al, p rogressive down h ill cou rse.
2. The answer is C. Becau se th is p atien t died with in 1 year o sh owin g sym p tom s, th is clin ical
p ictu re is m ost con sisten t with a p rion disease su ch as Creu tz eldt-Jakob disease. Th e NCDs
d u e to ron totem p oral d isease, Alzh eim er’s disease, Parkin son’s disease, an d Hu n tin gton’s
d isease typ ically p rogress over m an y years to death . Neu ro ibrillary tan gles are ou n d in
a n u m b er o n eu rodegen erative d iseases as well as n orm al agin g an d are n ot sp eci ic to
Alzh eim er’s d isease.
3. The answer is A. Th e p h ysician’s b est resp on se to th e m oth er’s statem en t is to get m ore
in orm ation , or exam p le, “Wh at d o you m ean by n ot eatin g well?” Recom m en din g ch an ges
in d iet or exercise or com m en tin g on th e ch ild’s ap p earan ce are n ot ap p rop riate u n til you
in d ou t m ore abou t th e m oth er’s p ercep tion o th e p roblem .
4. The answer is C. Low con cen tration o acetylch olin e is associated with th e sym p tom s
o Alzh eim er’s disease. Tacrin e, don ep ezil, rivastigm in e, an d galan tam in e are
acetylch olin esterase in h ib itors (i.e., th ey b lock th e b reakd own o Ach , in creasin g its
availability). Th ese agen ts can th u s b e e ective in slowin g down th e p rogression o th e
illn ess. Th ey do n ot restore th e u n ction th e p atien t h as already lost.
5. The answer is B. 6. The answer is C. Th e b est exp lan ation or th is p atien t’s sym p tom s is
p seu dod em en tia—dep ression th at m im ics dem en tia. In th e elderly, dep ression is o ten
associated with cogn itive p roblem s as well as sleep an d eatin g p rob lem s. Evid en ce or
d ep ression is p rovid ed by th e act th at th is p atien t’s sym p tom s began with th e loss o an
im p ortan t relation sh ip (i.e., th e death o h er dog). Deliriu m an d dem en tia are cau sed by
p h ysiological ab n orm alities in th e brain . Dissociative am n esia with dissociative u gu e
in volves wan derin g away rom h om e, an d n eu rocogn itive disorder du e to an oth er m edical
con dition is associated with a h istory o alcoh olism . Th e m ost e ective in terven tion or
th is dep ressed p atien t is an tid ep ressan t m edication . Wh en th e m edication relieves th e
d ep ressive sym p tom s, h er m em ory will im p rove. An tip sych otic m edication , p rovision o
a stru ctu red en viron m en t, acetylch olin esterase in h ibitors su ch as d on ep ezil, an d sim p le
reassu ran ce are n ot ap p rop riate or th is p atien t.
157
158 BRS Behavioral Science
7. The answer is C. 8. The answer is B. Th is p atien t is sh owin g eviden ce o Alzheim er’s disease.
He is h avin g accid en ts becau se h e is orget u l (e.g., orgettin g to tu rn o th e gas jet), an d
wan ders ou t o th e h ou se becau se he does n ot kn ow wh ich is th e closet or bath room door
an d wh ich is th e ou tsid e d oor. Th ere is n o evid en ce o a m ed ical cau se or h is sym p tom s,
as th ere wou ld b e in d eliriu m . Th ere is n o eviden ce o d ep ression , as in p seu dod em en tia,
or o a h istory o alcoh ol u se, as in n eu rocogn itive disorder du e to an oth er m edical
con d ition . Th e m ost e ective in itial in terven tion or th is p atien t is p rovision o a
stru ctu red en viron m en t (e.g., givin g th e p atien t visu al cu es or orien tation [labelin g doors
or u n ction ]) an d takin g p ractical m easu res (e.g., rem ovin g th e gas stove). Don ep ezil can
th en be u sed to slow th e p rogression o h is illn ess. Oth er m edication s an d reassu ran ce
m ay b e u se u l or sym p tom s su ch as p sych osis, dep ression , an d an xiety, bu t will h ave little
e ect on th e p atien t’s orget u l an d p oten tially dan gerou s beh avior.
9. The answer is D. Th is wom an , wh o eels as i sh e is “ou tsid e o h ersel ,” watch in g h er li e as
th ou gh it were a p lay, is sh owin g eviden ce o d ep erson alization / derealization disorder, a
p ersisten t eelin g o detach m en t rom on e’s own body or th e social situ ation . In con trast to
p sych otic d isorders su ch as sch izop h ren ia (see Ch ap ter 11), th is wom an is aware th at th is
p ercep tion is on ly a eelin g an d th at sh e is really livin g h er li e.
10. The answer is C. Th is stockbroker is sh owin g eviden ce o dissociative iden tity disorder. Sh e
does n ot rem em ber th e m an wh o sign ed th e letter or p osin g or th e p h otograp h becau se
th ese even ts occu rred wh en sh e was sh owin g an oth er p erson ality. Dissociative am n esia
in volves a ailu re to rem em ber im p ortan t in orm ation abou t on esel , an d dissociative
am n esia with dissociative u gu e is am n esia com bin ed with su dden wan derin g rom h om e
an d takin g on a di eren t id en tity. Dep erson alization / d erealization d isorder is a p ersisten t
eelin g o detach m en t rom on e’s own body, th e social situ ation , or th e en viron m en t
(derealization ) (an d see also an swer to Qu estion 9).
11. The answer is E. Th is wom an , wh o h as always elt em p ty an d alon e (n ot m erely lon ely),
sh ows eviden ce o borderlin e p erson ality disorder. Borderlin e p atien ts typ ically u se
sp littin g (see Ch ap ter 6) as a d e en se m ech an ism . Sel -in ju riou s beh avior an d im p u lsive
b eh avior (e.g., dru g u se, sex with m u ltip le p artn ers) also are ch aracteristic o p eop le with
th is p erson ality disorder.
12. The answer is E. Th is p atien t with m ild in tellectu al d isability an d associated p h ysical
in din gs p rob ably h as Down’s syn drom e, wh ich is associated with ch rom osom e 21. Down’s
syn drom e p atien ts o ten develop Alzh eim er’s disease in m iddle age, wh ich exp lain s th e
m em ory loss th at th is p atien t disp lays.
13. The answer is C. Th e doctor’s best statem en t to th e p atien t at th is tim e is, “Please tell m e
m ore ab ou t th e book th at you read.” It is im p ortan t to get as m u ch in orm ation as p ossible
rom th e p atien t be ore decidin g on a cou rse o action .
14. The answer is B. Th e m ost likely exp lan ation or th is clin ical p ictu re, th at is, h avin g n o
m em ory o a trau m atic even t with n o p h ysical in din gs, is dissociative am n esia. In PTSD
an d in adju stm en t disord er, th ere is n o ran k m em ory loss. Su barach n oid h em orrh age,
a h em orrh age in th e sp ace b etween th e arach n oid sp ace an d th e p ia m ater, typ ically
p resen ts with a “th u n d erclap” h eadach e, vom itin g, or oth er n eu rologic sym p tom s.
15. The answer is C. Th is typ ical 85-year-old p atien t is likely to show m in or orget uln ess, such
as orgettin g n ew n am es an d p hon e n um bers. Im paired con sciousn ess, p sych osis, an d
abn orm al level o arou sal are seen in deliriu m , wh ich is associated with a variety o p h ysical
illn esses. As in you n ger p eop le, in th e elderly dep ression is an illn ess (see Chapter 12), n ot a
n atu ral con sequ en ce o typ ical agin g.
Chapter 14 Neurocognitive, Personality, Dissociative, and Eating Disorders 159
16. The answer is D. 17. The answer is C. Th is wom an is already u n derweigh t yet wan ts to lose
m ore weigh t, an d sh e h as develop ed lan u go (growth o down y body h air) an d am en orrh ea
(absen ce o m en ses). Th ese in d in gs in d icate th at sh e h as an orexia n ervosa. Sin ce dan cers
an d gym n asts o ten m u st be sm all an d slim , th ese activities are closely associated with
th e develop m en t o an orexia n ervosa. An orexia is also ch aracterized by am ily con licts,
p articu larly with th e m oth er; n orm al ap p etite; h igh in terest in ood an d cookin g; low
sexu al in terest; good sch ool p er orm an ce; an d excessive exercisin g. Patien ts wh o h ave
an orexia n ervosa or an exten d ed p eriod (5 years in th is you n g wom an ) are at h igh risk or
osteop orosis.
18. The answer is C. Bu p rop ion is con train dicated in eatin g disorder p atien ts wh o also p u rge
becau se it can lower th e seizu re th resh old . Th e on ly an tidep ressan t th at is FDA ap p roved
or p atien ts with b u lim ia n ervosa is lu oxetin e.
19. The answer is E. Th is clin ical p ictu re is m ost con sisten t with n orm al sh yn ess. Alth ou gh
th is 20-year-old p atien t is som ewh at an xiou s arou n d wom en , th e act th at h e h as rien ds
an d is doin g well in h is job m akes it u n likely th at h e h as a p erson ality disorder or au tism
sp ectru m disorder (see Ch ap ter 15).
20. The answer is A. Th e m ost ap p rop riate irst recom m en d ation or th e m an agem en t o
th is p atien t is to ask th e wi e to in crease h om e n igh ttim e ligh tin g. Ligh tin g will im p rove
th e p atien t’s ability to n egotiate th e ap artm en t at n igh t an d so redu ce h is n octu rn al
disorien tation . Keep in g th e wi e awake is n ot p ractical or p ositive or h er an d m ech an ical
restrain ts sh ou ld b e avoided i p ossib le (see also an swers to Qu estion s 7 an d 8).
21. The answer is J . Th is 38-year-old m an , wh o asks to be re erred to a p h ysician wh o
atten ded a top -rated m edical sch ool becau se h e is “better” th an oth er p atien ts, is sh owin g
evid en ce o n arcissistic p erson ality d isorder (see also an swers to Qu estion s 22–28).
22. The answer is A. Th is 20-year-old college stu den t, wh o m ade a su icide attem p t a ter a
relatively trivial relation sh ip b roke u p an d wh o u ses sp littin g as a de en se m ech an ism (e.g.,
all o th e oth er doctors sh e h as seen were terrib le an d th is d octor is p er ect), is sh owin g
evid en ce o borderlin e p erson ality d isorder.
23. The answer is B. Th is 28-year-old wom an wh o brin gs gi ts or th e recep tion ist an d
th e n u rses b ecau se sh e n eeds everyon e’s atten tion is sh owin g eviden ce o h istrion ic
p erson ality disorder. Patien ts with th is p erson ality disorder ten d to exaggerate th eir
p h ysical sym p tom s or d ram atic e ect (e.g., “a ever o at least 106°F”).
24. The answer is I. Th is 50-year-old wom an , wh o agreed to start an exercise p rogram an d
th en m akes weak excu ses or h er ailu re to ollow th e p rogram , is sh owin g evid en ce o
p assive–aggressive p erson ality d isorder. Sh e did n ot really wan t to ollow th e doctor’s
exercise p rogram (was in wardly de ian t) bu t agreed to do it (was ou twardly com p lian t).
25. The answer is L. Th is 26-year-old wom an , wh o sh ows n o eviden ce o a th ou gh t disorder,
h as n o rien ds, an d sp en d s m ost o h er tim e at solitary p u rsu its, is sh owin g eviden ce o
sch izoid p erson ality disorder. Patien ts with sch izoid p erson ality disorder are typ ically
con ten t with th eir solitary li estyle.
26. The answer is C. Th is m edical stu d en t, wh o m u st con stan tly m ake lists an d review an d
m em orize h er n otes, is sh owin g eviden ce o obsessive–com p u lsive p erson ality disorder.
Th is beh avior is ultim ately in e icien t an d h as resu lted in h er academ ic p roblem s.
27. The answer is F. Th is abu sed m an is sh owin g eviden ce o dep en den t p erson ality disorder.
He tolerates h is p artn er’s ab u se b ecau se o h is overridin g ear o bein g deserted by h is
lover, b ein g alon e, an d h avin g to m ake h is own decision s.
28. The answer is D. Th is 20-year-old em ale college stu den t sh ows eviden ce o avoidan t
p erson ality disorder. Sh e is so overwh elm ed by wh at sh e p erceives as criticism an d
rejection th at sh e drop s ou t o sch ool rath er th an ace h er teach er an d classm ates again .
Psych iatric Disorders in
c ha pte r
15 Ch ildren
160
Chapter 15 Psychiatric Disorders in Children 161
C. Related disorders
1. Rett’s syndrome in volves:
a. Dim in ish ed social, verbal, an d cognitive development a ter u p to 4 years o n orm al
u n ction in g.
b. Occu rren ce on ly in girls (Rett’s syn d rom e is X lin ked, sp eci ically Xq28, an d a ected
m ales typ ically die b e ore birth ).
c. Stereotyp ed, hand-wringing m ovem en ts; ataxia.
d. Breathing p roblem s.
e. In tellectu al disability.
f. Motor p rob lem s later in th e illn ess.
2. Selective mutism in volves:
a. Sp eakin g in som e social situ ation s (e.g., at h om e) bu t n ot in oth ers (e.g., at sch ool).
b. More com m on occu rren ce in girls .
c. Whispering or com m u n icatin g on ly with hand gestures .
d. Selective m u tism m u st be distin gu ish ed rom typ ical sh yn ess.
Attention-Deficit/Hyperactivity
Disorder (ADHD) Conduct Disorder Oppositional Defiant Disorder
Characteristics (must be present in at least two settings, e.g., at home and at school)
Hyperactivity Behavior that grossly violates social Behavior that, while defiant, negative,
Inattention norms (e.g., torturing animals, and noncompliant, does not grossly
Impulsivity stealing, truancy, fire setting) violate social norms (e.g., anger,
Carelessness argumentativeness, resentment
Propensity for accidents toward authority figures)
History of excessive crying, high
sensitivity to stimuli, and irregular
sleep patterns in infancy
Symptoms present before age 12
Prognosis
Hyperactivity is the first symptom to Can begin in childhood (ages 6–10) or Gradual onset, usually before age 8
disappear as the child reaches adolescence (no symptoms prior
adolescence to age 10)
Risk for conduct disorder and Risk for criminal behavior, antisocial A significant number of cases progress
oppositional defiant disorder personality disorder, substance use to conduct disorder
disorders, and depressive disorders
in adulthood
Most children show remission by Most children show remission by Most children show remission by
adulthood adulthood adulthood
B. Etiology
1. Genetic factors are in volved. Relatives o ch ildren with con du ct disorder an d ADHD h ave
an in creased in cid en ce o th ese disord ers an d o antisocial personality disorder an d sub-
stance use disorders .
2. Alth ou gh evid en ce o seriou s stru ctu ral p rob lem s in th e brain is n ot p resen t, ch ildren
with con d u ct disorder an d ADHD m ay h ave minor brain dysfunction.
3. Su bstan ce u se d isord ers, seriou s p aren tal discord, an d dep ressive disorders are seen in
som e p aren ts o ch ild ren with th ese d isord ers; becau se o th eir p roblem atic beh avior,
th ese ch ildren are also more likely to be abused by p aren ts or caretakers.
4. Th ere is no scientific basis or claim s o an association between ADHD an d eith er im p rop er
diet (e.g., excessive su gar in take) or ood allergy (e.g., arti icial colors or lavors).
C. Management
1. Ph arm acologic treatm en t or ADHD con sists o u se o cen tral n ervou s system (CNS)
stimulants in clu din g m eth ylp h en idate (Ritalin , Con certa), dextroam p h etam in e su l ate
(Dexed rin e), a com bin ation o am p h etam in e an d dextroam p h etam in e (Adderall), an d
dexm eth ylp h en id ate (Focalin ). Atomoxetine (Strattera) is a norepinephrine reuptake inhibi-
tor, also in dicated or ADHD.
a. For ADHD, CNS stim u lan ts ap p aren tly h elp reduce activity level and increase attention
span an d th e ab ility to con cen trate; an tid ep ressan ts also m ay b e u se u l.
b. Sin ce stim u lan t dru gs decrease appetite (see Ch ap ter 9), th ey m ay in h ibit growth an d
lead to failure to gain weight; both growth an d weigh t u su ally retu rn to n orm al on ce th e
ch ild stop s takin g th e m edication .
2. Family therapy is th e m ost e ective m an agem en t or con du ct disorder an d op p osition al
de ian t disord er (see Ch ap ter 17).
Chapter 15 Psychiatric Disorders in Children 163
Sin ce th e age o 8, a 15-year-old girl with n or- A 9-year-old boy with norm al intelligence re-
m al in telligen ce an d social skills h as sh own a quently gets into trouble at school because he
n u m b er o rep etitive m otor m ovem en ts. Sh e blurts out answers, interrupts the teacher, dis-
recen tly h as begu n to h ave ou tbu rsts in wh ich turbs the other students, and cannot seem to sit
sh e cu rses an d sh rieks. Wh en asked i sh e can still in class. He also requently injures him sel
con trol th e vocalization s an d m ovem en ts sh e during play and rarely sits through an entire m eal
says, “For a sh ort tim e on ly; it is like h oldin g at hom e. His siblings say that he is “a real pest.”
you r breath —even tu ally you h ave to let it However, the child does his schoolwork well and
ou t.” Med ical evalu ation is u n rem arkab le. behaves well when he is alone with his tutor.
13. Th e p aren ts o a 10-year-old ch ild rep ort 14. Th e p aren ts o an 8-year-old boy rep ort
th at th e ch ild is still wettin g th e b ed . Th e th at h is beh avior at h om e is p rob lem atic. He
ch ild is very u p set ab ou t th is b ecau se h e re u ses to d o h is ch ores an d o ten gh ts with
wou ld like to go away to su m m er cam p b u t is h is 6-year-old broth er an d 11-year-old sister.
a raid th at h e will wet th e bed th ere as well. His teach ers rep ort th at h e is well beh aved
Ph ysical exam in ation is u n rem arkab le an d at sch ool, is workin g at th e exp ected level,
th e ch ild is oth erwise d evelop in g typ ically an d gets alon g well with th e oth er ch ildren .
or h is age. Beh avioral in terven tion s su ch as Medical exam in ation is u n rem arkable. Th e
lim itin g f u ids b e ore b ed an d th e b ell an d m ost likely exp lan ation or th is p ictu re is
p ad ap p aratu s h ave n ot been e ective. At (A) op p osition al d e ian t d isord er
th is tim e, wh ich o th e ollowin g is th e b est (B) atten tion -de icit/ h yp eractivity disord er
ch oice or p h arm acologic m an agem en t o (C) social d i icu lties in th e am ily
en uresis in th is ch ild? (D) con d u ct d isord er
(A) Im ip ram in e (E) typ ical age-ap p rop riate beh avior
(B) Diazep am
(C) Desm op ressin acetate
(D) Acetam in op h en
(E) Asp irin
An swers an d Exp lan ation s
1. The answer is D. 2. The answer is A. Th is girl is m ost likely to h ave Tou rette’s disorder, a
ch ron ic n eu rologic con d ition with beh avioral m an i estation s su ch as u n wan ted m otor
activity an d vocalization s. Th e vocalization s an d m otor tics can be con trolled on ly brie ly
an d th en th ey m u st be exp ressed . ASD an d Rett’s syn drom e are develop m en tal disorders
o ch ildh ood th at are ch aracterized by abn orm al social in teraction an d sp eech . ADHD
in volves n orm al develop m en t o sp eech an d social in teraction bu t di icu lty p ayin g
atten tion or sittin g still. Selective m u tism in volves volu n tary absen ce or decrease in
sp eakin g in social situ ation s. Th e m ost e ective m an agem en t or Tou rette’s disorder is
an tip sych otic m ed ication , su ch as h alop eridol. Th ere is n o eviden ce th at an tidep ressan ts
or stim u lan ts are h elp u l or con trol o m otor or vocal tics. Psych oth erapy can h elp p atien ts
with Tou rette’s disorder deal with the social p roblem s th eir disorder m ay cau se, bu t is n ot
th e m ost e ective m an agem en t or th e sym p tom s o th e d isorder.
3. The answer is A. Th is ch ild , wh o h as n ever sp oken volu n tarily an d wh o sh ows n o in terest
in or con n ection to h is p aren ts, oth er adu lts, or oth er ch ildren desp ite n orm al h earin g,
p robably h as ASD. He tu rn s on th e tap to watch th e water ru n n in g becau se, as with m an y
ch ild ren with ASD, rep etitive m otion calm s h im . An y ch an ge in h is en viron m en t, su ch as
b ein g d ressed , lead s to in ten se d iscom ort, stru gglin g, an d scream in g (see also an swer to
Qu estion 1).
4. The answer is B. 5. The answer is C. 6. The answer is D. 7. The answer is D. Th is 9-year-
old boy wh o gets in to trou ble at sch ool becau se h e distu rbs th e teach er an d th e oth er
stu d en ts, h as b eh avioral di icu lties at h om e an d with sib lin gs, an d can n ot seem to sit still
is sh owin g eviden ce o ADHD (see also an swer to Qu estion 1). Ch ildren with ADHD can
o ten learn well wh en th ere are ew distraction s (e.g., alon e with a tu tor). Ch ildren with
con du ct d isorder sh ow b eh avior th at violates social n orm s (e.g., stealin g). In con trast,
ch ild ren with ADHD h ave trou ble con trollin g th eir beh avior bu t do n ot in ten tion ally cau se
h arm . Ch ildren with op p osition al de ian t disorder h ave p roblem s dealin g with au th ority
igu res bu t n ot with oth er ch ildren or an im als. ADHD is believed to resu lt rom n eu rologic
d ys u n ction . Alth ou gh an ecdotal evid en ce h as been p u t orward, scien ti ic stu dies h ave
n ot revealed an association b etween ADHD an d eith er im p rop er diet (e.g., excessive su gar
in take) or ood allergy (e.g., to arti icial colors or lavors). Th e disorder also is n ot a resu lt
o p aren tin g style (e.g., excessive p u n ish m en t or len ien cy). However, in part becau se o
th eir di icu lt beh avior, ch ild ren with ADHD are m ore likely to b e p h ysically ab u sed by
p aren ts. Th e m ost e ective m an agem en t or ch ildren with ADHD is u se o cen tral n ervou s
system stim u lan ts in clu d in g m eth ylp h en id ate (Ritalin ), an d d extroam p h etam in e su l ate
(Dexedrin e). Lith iu m is u sed to treat b ip olar disorder, an tidep ressan ts are u sed p rim arily
to treat dep ression , an d sedatives are u sed p rim arily to treat an xiety. Wh ile p sych oth erapy
m ay h elp th e p aren ts an d ch ild deal with th e b eh avioral sym p tom s, it is n ot th e m ost
e ective m an agem en t sin ce th e disord er is based on n eu rologic dys u n ction . Ch ildren with
ADHD are at h igh er risk th an oth er ch ild ren or op p osition al d e ian t d isord er an d con d u ct
d isorder.
167
168 BRS Behavioral Science
8. The answer is A. Th is ch ild is sh owin g evid en ce o sep aration an xiety d isorder. By th e age
o 3 to 4 years ch ild ren sh ou ld be able to sp en d som e tim e away rom p aren ts in a sch ool
settin g. Th e p ed iatrician’s b est recom m en dation is or th e p aren ts to go to sch ool with th e
ch ild an d , over days, grad u ally d ecrease th e tim e th ey sp en d th ere. Allowin g th e ch ild to
stay at h om e or h irin g a h om e tu tor will ju st in crease th e ch ild’s d i icu lty sep aratin g rom
h is p aren ts. Ph arm acologic th erapy is n ot th e irst ch oice in th e m an agem en t o th is ch ild.
9. The answer is D. Th is ch ild is sh owin g evid en ce o con d u ct disord er. Ch ild ren with th is
disord er h ave little or n o con cern or oth ers or or an im als (e.g., th is ch ild in ds tortu rin g
an im als “ u n”) (see also an swer to Qu estion 4).
10. The answer is D. 11. The answer is E. Th is ch ild wh o d oes n ot wan t to b e h eld , cries wh en
h is en viron m en t is ch an ged (e.g., wh en bath ed ), an d does n ot m ake eye con tact is likely to
h ave ASD. Ch ildren with ASD h ave great d i icu lty with in terp erson al relation s. Problem s
with atten tion an d con cen tration are m ore ch aracteristic o ADHD. Ch ild ren with con du ct
d isord er ten d to h ave p oor sel -con trol an d to b reak societal ru les. Hyp eractivity m ay
b e p resen t b u t is n ot sp eci ically associated with ASD. Th e m ajor ch aracteristic th at
d i eren tiates Level 1 rom Level 3 au tism sp ectru m disorder is th at in th e latter bu t n ot in
th e orm er, th ere is d evelop m en tal lan gu age d elay an d th is ch ild sh ows relatively n orm al
lan gu age develop m en t, restricted or u n u su al in terests (h ere, in ten se ocu s on state licen se
p lates), sp ecial ab ilities, ocu s on keep in g u p rou tin es an d p roblem s in p eer relation sh ip s
are ch aracteristic o all levels o au tism sp ectru m disorder.
12. The answer is B. Th is ch ild wh o sh ows evid en ce o Tou rette’s disorder is at risk to develop
ob sessive–com p u lsive d isord er (OCD) in ad u lth ood. Both disorders in volve dys u n ction o
th e cau date n u cleu s. Seizu re disorders, con du ct disorder, sch izop h ren ia, an d ASD are n ot
p articu larly associated with Tou rette’s disorder (see also an swer to Qu estion 1).
13. The answer is C. Th e best ch oice or th e p h arm acologic m an agem en t o b edwettin g in an
older ch ild su ch as th is is d esm op ressin acetate. Im ip ram in e is also u se u l in m an agin g
en u resis b u t h as m ore sid e e ects. Diazep am (a b en zod iazep in e), u sed to treat an xiety,
an d acetam in op h en an d asp irin , u sed in th e m an agem en t o m in or p ain , are n ot u se u l in
m an agin g en u resis.
14. The answer is C. Th e m ost likely exp lan ation or wh y th is ch ild m isbeh aves at h om e bu t
n ot at sch ool is that th ere are social di icu lties in th e am ily, or exam p le, p roblem s in th e
relation sh ip between th e m oth er an d ath er. In con trast, ch ildren with con du ct disorder
sh ow b eh avior th at violates social n orm s (e.g., stealin g), ch ildren with ADHD h ave trou ble
con trollin g th eir beh avior, an d ch ild ren with op p osition al de ian t disorder h ave p roblem s
dealin g with au th ority igu res. In th ese d isorders, beh avioral d i icu lties typ ically are
p resen t both at h om e an d at sch ool.
Biologic Th erap ies:
c ha pte r
16 Psych op h arm acology
I. OVERVIEW
A. Neurotransmitter abnormalities are in volved in th e etiology o m an y p sych iatric illn esses (e.g.,
p sych otic d isord ers, dep ressive an d bip olar disorders, an xiety disorders) (see Ch ap ter 4).
B. Alth ou gh n orm alization o n eu rotran sm itter levels by pharmacologic agents can am eliorate
m an y o th e sym p tom s, th ese agen ts do not cure p sych iatric disorders.
169
170 BRS Behavioral Science
2. An tip sych otics are also u sed m ed ically to treat n au sea, h iccu p s, in ten se an xiety an d agita-
tion , an d Tou rette’s disorder.
3. Alth ou gh an tip sych otics com m on ly are taken daily by m ou th , n on adh eren t p atien ts can
be treated with lon g-actin g “depot” orm s, su ch as haloperidol decanoate or fluphenazine
decanoate ad m in istered in tram u scu larly every 2–4 weeks.
4. An an tip sych otic agen t can be classi ied as traditional (i.e., typical) or atypical dep en din g
on its m ode o action an d side e ect p ro ile.
C. Atypical an tip sych otic agen ts (e.g., arip ip razole [Abili y], clozap in e [Clozaril], olan zap in e
[Zyp rexa], risp eridon e [Risp erdal], qu etiap in e [Seroqu el], zip rasidon e [Geodon ], asen ap in e
[Sap h ris], ilop eridon e [Fan ap t], lu rasidon e [Latuda], an d p alip eridon e [In vega])
1. In con trast to tradition al an tip sych otic agen ts, a m ajor m ech an ism o action o atyp i-
cal an tip sych otics ap p ears to be on serotonergic systems . Th ey also a ect dop am in ergic
recep tors in addition to D 2 (e.g., D 1, D 3, an d D 4).
Adverse
Effect Aripiprazole Clozapine Olanzapine Risperidone Quetiapine Ziprasidone Asenapine Iloperidone Lurasidone Paliperidone
EPS, extrapyramidal symptoms; MBS, metabolic syndrome (weight gain, diabetes mellitus); ±, few if any; +, mild; ++, moderate; +++, severe;
++++, very severe.
a
The assistance of Meredith Brandon, MD, in compiling this table is gratefully appreciated.
2. Som e o th e atyp ical an tip sych otics are also in dicated to treat bipolar disorder.
3. Advantages o atyp ical agen ts over tradition al agen ts
a. Atyp ical agen ts, p articu larly clozap in e, m ay be more effective wh en u sed to treat th e
negative , ch ron ic, an d re ractory symptoms o sch izop h ren ia (see Ch ap ter 11).
b. Th ey are less likely to cause adverse neurological symptoms an d dyston ias (Table 16.1)
an d so are n ow th e first-line agen ts or treatin g ch ron ic p sych iatric disorders su ch as
sch izop h ren ia.
4. Disadvantages o atyp ical agen ts
a. Atyp ical agen ts m ay in crease th e likelih ood o blood dyscrasias su ch as agranulocytosis
(very low gran u locyte cou n t lead in g to severe in ection s), with clozapine as th e m ost
p roblem atic agen t.
b. Th ey m ay also in crease th e likelih ood o seizures , m etabolic ab n orm alities lead in g to
weight gain, an tich olin ergic side e ects, an d p an creatitis.
c. Som e atyp ical agen ts h ave m ore adverse e ects th an oth ers. Table 16.2 p rovides
th e ad verse e ects or d i eren t atyp ical agen ts with resp ect to m etabolic syn drom e
in clu d in g weight gain and type 2 diabetes, EPS and prolactin elevation, sedation, an d car-
d iovascu lar e ects su ch as prolongation of the QT interval.
Other Antidepressants
Amoxapine (Asendin) Antidopaminergic effects (e.g., Depression with psychotic features
parkinsonian symptoms,
galactorrhea, sexual dysfunction)
Most dangerous in overdose
Bupropion (Wellbutrin, Zyban, Insomnia Smoking cessation (Zyban)
Contrave) Seizures: avoid in eating disorder Major depressive disorder with seasonal pattern
patients who purge SSRI-induced sexual dysfunction
Sweating Adult ADHD
Few adverse sexual effects Obesity (Contrave)
Mirtazapine (Remeron) Increased appetite Insomnia
Trazodone (Desyrel, Oleptro) Sedation Insomnia
Priapism
Hypotension
Vilazodone (Viibryd) Few adverse sexual effects Indicated only for major depressive disorder
D. MAOIs
1. MAOIs in h ibit th e breakdown o n eu rotran sm itters by m on oam in e oxidase A (MAOA) in
th e brain in an irreversible reaction .
2. Th ese agen ts m ay be p articu larly u se u l in th e m an agem en t o atypical depression (see
Ch ap ter 12) an d treatm en t resistan ce to oth er agen ts.
3. A m ajor drawback o u sin g MAOIs is a p oten tially fatal reaction wh en th ey are taken in
con ju n ction with certain ood s or m ed ication s. Th is reaction occu rs becau se
a. MAO metabolizes tyramine, a pressor, in th e gastroin testin al tract.
174 BRS Behavioral Science
b. I MAO is in h ibited, in gestion o tyramine-rich foods (e.g., aged ch eese, beer, win e,
broad b ean s, b ee or ch icken liver, an d sm oked or p ickled m eats or ish ) can in crease
tyram in e levels.
c. In crease in tyram in e can cau se elevated blood p ressure, sweatin g, h eadache, an d vom -
itin g (i.e., the noradrenergic or hypertensive crisis ), wh ich in turn can lead to stroke an d
death.
d. Use o sympathomimetic drugs (e.g., ep h edrin e, m ethylphen idate [Ritalin ], phen yleph-
rin e [Neo-Syn ephrin e], pseudoephedrin e [Suda ed]) can have the sam e e ect an d m ust
be avoided.
4. Oth er adverse e ects o MAOIs are sim ilar to th ose o th e h eterocyclics, in clu din g dan ger
in overd ose.
5. The serotonin syndrome
a. MAOIs an d SSRIs or HCAs u sed togeth er as well as MAOIs u sed alon g with seroton ergic
an algesics su ch as meperidine (Dem erol) or tramadol (Ultram ) can cau se a p oten tially
atal d ru g–dru g in teraction , th e seroton in syn drom e.
b. Th is syn drom e is ch aracterized by high fever, au ton om ic in stability, h eadach e, sei-
zu res, deliriu m , n au sea, diarrh ea, vom itin g, an d m yoclon u s (m u scle sp asm s).
c. To avoid th is reaction , th e recom m en d ed washout period or an SSRI or an HCA b e ore
startin g an MAOI is 5 weeks an d 2 weeks, resp ectively.
d. See Table 16.4 or a comparison of three life-threatening syndromes (each ollowed
with a m n em on ic) associated with u se o p sych oactive m edication s: Th e n eu rolep tic
m align an t syn drom e (FALTER), seroton in syn d rom e (FADEM), an d h yp erten sive crisis
(ETHICS).
Neurotransmitter
Syndrome Basis Causative Agents Symptoms Lab Findings Management
V. ANTIANXIETY AGENTS
A. Benzodia zepines (BZs)
1. BZs activate b in d in g sites on th e g-aminobutyric acid A (GABAA) receptor, th ereby decreas-
in g n eu ron al an d m u scle cell irin g.
2. Th ese agen ts h ave a sh ort, in term ed iate, or lon g on set an d du ration o action an d m ay be
u sed to treat disorders oth er th an an xiety disorders (Table 16.5).
3. Th eir ch aracteristics o action are related to th eir clin ical in dication s an d th eir p oten tial
or addiction ; or exam p le, sh ort-actin g agen ts are good h yp n otics (sleep in du cers) bu t
h ave a h igh er p oten tial or ad diction th an lon ger-actin g agen ts.
4. BZs com m on ly cau se sedation bu t h ave ew oth er adverse e ects in adu lts.
5. Tolerance an d dependence m ay occu r with ch ron ic u se o th ese agen ts an d with drawal
sym p tom s can b e li e-th reaten in g.
176 BRS Behavioral Science
Benzodiazepines
Clorazepate (Tranxene) Short Adjunct in management of partial seizures
Triazolam (Halcion) Short Insomnia
Alprazolam (Xanax) Intermediate Depression, panic disorder, social anxiety disorder
Lorazepam (Ativan) Intermediate Psychotic agitation, alcohol withdrawal, acute control of
seizures
Temazepam (Restoril) Intermediate Insomnia
Chlordiazepoxide (Librium) Long Alcohol withdrawal (particularly for agitation)
Clonazepam (Klonopin) Long Seizures, mania, social anxiety disorder, panic disorder,
obsessive–compulsive disorder
Diazepam (Valium) Long Muscle relaxation, analgesia, seizures, alcohol withdrawal
(particularly for seizures)
Flurazepam (Dalmane) Long Insomnia
Nonbenzodiazepines
Ramelteon (Rozerem) Short Indicated only for insomnia
Zaleplon (Sonata) Short Indicated only for insomnia
Zolpidem (Ambien) Short (longer-acting “CR” Indicated only for insomnia
version available)
Eszopiclone (Lunesta) Intermediate Indicated only for insomnia
Buspirone (BuSpar) Very long Anxiety in the elderly, generalized anxiety disorder
6. Flumazenil (Mazicon , Rom azicon ) is a BZ recep tor an tagon ist th at can reverse th e e ects
o BZs in cases o overd ose or wh en BZs (e.g., m idazolam [Versed]) are u sed or sedation
d u rin g m ed ical or su rgical p roced u res.
B. Nonbenzodiazepines
1. Buspirone (Bu Sp ar), an azasp irodecan edion e, is n ot related to th e BZs.
a. In con trast to BZs, bu sp iron e is n on sedatin g an d is not associated with dependence,
addiction, or withdrawal p roblem s.
b. It is u sed p rim arily to treat con d ition s cau sin g ch ron ic an xiety, in wh ich BZ d ep en -
den ce can becom e a p rob lem (e.g., generalized anxiety disorder) (see Ch ap ter 13).
c. Bu sp iron e takes up to 2 weeks to work an d m ay n ot be accep table to p atien ts wh o are
accu stom ed to takin g th e ast-actin g BZs or th eir sym p tom s.
2. Zolpidem (Am bien ), zaleplon (Son ata), eszopiclone (Lu n esta), an d ramelteon (Rozerem ) are
sh ort-actin g agen ts u sed p rim arily to treat in som n ia (see Ch ap ter 10). Like th e BZs, th e
irst th ree o th ese agen ts act on th e GABAA recep tor. In con trast, ram elteon is a selective
melatonin agonist.
3. Antihypertensives in clu din g β-blockers (block both α1- an d β2-adren ergic recep tors) su ch as
p rop ran olol (In deral) an d α2-ad ren ergic recep tor an tagon ists su ch as clon id in e (Catap res)
d ecrease au ton om ic h yp erarou sal an d are u sed to treat sym p tom s o an xiety (e.g., tach y-
cardia), p articu larly in p atien ts with social an xiety su ch as ear o p u blic sp eakin g.
B. Th e p oten tial ben e its o m an y p sych oactive agen ts m ay warran t th eir u se du rin g p regn an cy.
Table 16.6 lists th e Food an d Dru g Adm in istration (FDA) p regn an cy categories or p sych oac-
tive agen ts. For exam p le, m ost an tid ep ressan ts an d an tip sych otics are in FDA p regn an cy
category C. In con trast, b ecau se BZs m ay cau se breath in g di icu lties, “ lop py” m u scles, an d
oth er ad verse e ects in n ewb orn s o m oth ers wh o u se th em d u rin g p regn an cy, th ese agen ts
are in FDA p regn an cy categories D and X.
Chapter 16 Biologic Therapies: Psychopharmacology 177
Pregnancy
Category Antipsychotics Antidepressants Mood Stabilizers Antianxiety Agents
B. Administration
1. ECT in volves th e in d u ction o a generalized seizure , lastin g 25–60 secon ds, by passing an
electric current across the brain.
178 BRS Behavioral Science
2. Prior to seizu re in du ction , th e p atien t is premedicated (e.g., with atrop in e), th en adm in -
istered a sh ort-actin g gen eral an esth esia (e.g., m eth ohexital) an d a m u scle relaxan t (e.g.,
su ccin ylch olin e) to p reven t in ju ry d u rin g th e seizu re.
3. Im p rovem en t in m ood typ ically begins after a few ECT treatments . A m axim u m resp on se to
ECT is u su ally seen a ter 5–10 treatm en ts given over a 2- to 3-week p eriod.
179
180 BRS Behavioral Science
15. A 30-year-old m an with sch izop h ren ia 19. Wh at is th e an tidep ressan t agen t
h as been very with d rawn an d ap ath etic or m ost likely to cau se p ersisten t erection s
m ore th an 10 years. He n ow is takin g an (p riap ism ) in a 40-year-old m ale p atien t?
an tip sych otic agen t th at is h elp in g h im to (A) Ven la axin e
b e m ore ou tgoin g an d sociable. However, (B) Tran ylcyp rom in e
th e p atien t is exp erien cin g seizu res an d (C) Trazodon e
agran u locytosis. Th e an tip sych otic agen t (D) Doxep in
th at th is p atien t is m ost likely to be takin g is (E) Am oxap in e
(A) risp eridon e (F) Flu oxetin e
(B) th ioridazin e (G) Nortrip tylin e
(C) olan zap in e (H) Im ip ram in e
(D) h alop eridol
(E) clozap in e 20. Wh ich o th e ollowin g an tidep ressan t
agen ts is m ost likely to cau se gyn ecom astia
Questions 16 and 17 an d p arkin son ian sym p tom s in a 45-year-old
m ale p atien t?
A 30-year-old p atien t is b rou gh t to th e em er- (A) Ven la axin e
gen cy dep artm en t a ter bein g ou n d ru n n in g (B) Tran ylcyp rom in e
down th e street n aked . He is sp eakin g very (C) Trazodon e
qu ickly an d tells th e p h ysician th at h e h as (D) Doxep in
ju st given h is cloth in g an d all o h is m on ey (E) Am oxap in e
to a h om eless m an . He states th at God sp oke (F) Flu oxetin e
to h im an d told h im to do th is. th e m edical (G) Nortrip tylin e
exam is u n rem arkab le. His h istory reveals (H) Im ip ram in e
th at h e is a p racticin g attorn ey wh o is m ar-
ried with th ree ch ildren . 21. Wh at is th e m ost ap p rop riate
an tidep ressan t agen t or rap id relie o th e
16. Th e m ost e ective im m ed iate sym p tom s o dep ression in a 25-year-old
m an agem en t or th is p atien t is wom an ?
(A) lith iu m (A) Ven la axin e
(B) lu oxetin e (B) Tran ylcyp rom in e
(C) am itrip tylin e (C) Trazodon e
(D) bu sp iron e (D) Doxep in
(E) h alop eridol (E) Am oxap in e
(F) Flu oxetin e
17. Th e m ost e ective lon g-term (G) Nortrip tylin e
m an agem en t or th is p atien t is (H) Im ip ram in e
(A) lith iu m
(B) lu oxetin e 22. Wh ich o th e ollowin g an tidep ressan t
(C) am itrip tylin e agen ts is m ost likely to cau se extrem e
(D) bu sp iron e sedation ?
(E) h alop eridol (A) Ven la axin e
(B) Tran ylcyp rom in e
18. Wh at is th e m ost ap p rop riate agen t or (C) Trazodon e
a d octor to recom m en d or a 34-year-old , (D) Doxep in
overweigh t, dep ressed p atien t wh o n eed s (E) Am oxap in e
to take an an tid ep ressan t bu t is a raid o (F) Flu oxetin e
gain in g weigh t? (G) Nortrip tylin e
(A) Ven la axin e (H) Im ip ram in e
(B) Tran ylcyp rom in e
(C) Trazodon e
(D) Doxep in
(E) Am oxap in e
(F) Flu oxetin e
(G) Nortrip tylin e
(H) Im ip ram in e
182 BRS Behavioral Science
29. Wh ich o th e ollowin g is th e m ost 31. Wh at is th e p rim ary m ech an ism o action
ap prop riate resp on se by th e p h ysician ? o the dru g o ch oice to treat bu lim ia in a
(A) “Dep ression associated with p regn an cy 29-year-old wom an ?
is u n related to m ajor dep ression ; (A) Ap p etite su p p ression
th ere ore, you are n ot at greater risk or (B) An tiem etic
bein g dep ressed wh ile p regn an t.” (C) Norep in ep h rin e reu p take in h ib ition
(B) “Th e risk or dep ression is greatest (D) Seroton in reu p take in h ibition
a ter d elivery an d dep ression d u rin g (E) Dop am in e an tagon ism
p regn an cy can o ten be sa ely treated.”
(C) “Th e risk or dep ression is greatest 32. A 26-year-old m an p resen ts to th e
du rin g p regn an cy, bu t ECT is qu ite sa e.” em ergen cy dep artm en t with elevated blood
(D) “Sin ce you h ave b een sym p tom - ree p ressu re, sweatin g, h eadach e, an d vom itin g.
or th e p ast year, you sh ou ld n ot b e at His com p an ion tells th e p h ysician th at th e
greatest risk or dep ression th an th e p atien t becam e ill at a p arty wh ere h e ate
n orm al p op u lation .” p izza an d d ran k alcoh olic p u n ch . Th e dru g
(E) “We will n eed to ollow you closely sin ce th at th is p atien t is m ost likely to be takin g is
th e su icide rate is h igh er or wom en wh o (A) lu oxetin e
are p regn an t th an or wom en wh o are (B) lith iu m
n ot p regn an t.” (C) n ortrip tylin e
(D) tran ylcyp rom in e
30. I th e doctor decides to p rescribe an (E) h alop eridol
an tidep ressan t or th is p atien t du rin g
p regn an cy, wh ich o th e ollowin g SSRIs
sh ou ld b e avoid ed?
(A) Citalop ram
(B) Escitalop ram
(C) Flu oxetin e
(D) Paroxetin e
(E) Sertralin e
An swers an d Exp lan ation s
1. The answer is C. 2. The answer is D. Th e sym p tom th at th is p atien t d escrib es is akath isia,
a su b jective, u n com ortab le eelin g o m otor restlessn ess related to u se o som e
an tip sych otics. Restless legs syn drom e also in volves u n com ortable sen sation s in th e legs,
bu t it is a sleep disord er (see Ch ap ter 10), wh ich cau ses di icu lty allin g an d stayin g asleep.
Oth er an tip sych otic sid e e ects in clu de n eu rolep tic m align an t syn drom e (h igh ever,
sweatin g, in creased p u lse an d blood p ressu re, an d m u scu lar rigidity), p seu dop arkin son ism
(m u scle rigid ity, sh u lin g gait, restin g trem or, an d m ask-like acial exp ression ), an d tardive
dyskin esia (in volu n tary m ovem en ts in clu din g ch ewin g an d lip -sm ackin g). High -p oten cy
an tip sych otics, su ch as h alop eridol, are m ore likely to cau se th ese n eu rologic side e ects
th an low-p oten cy agen ts, su ch as th iorid azin e, or atyp ical agen ts, su ch as risp erid on e,
olan zap in e, an d clozap in e.
3. The answer is D. 4. The answer is A. Th ese in volu n tary ch ewin g an d lip -sm ackin g
m ovem en ts in dicate th at th e p atien t h as develop ed tardive dyskin esia, a seriou s an d
rarely reversib le sid e e ect o treatm en t with an tip sych otic m edication (see also an swer to
Qu estion 1). Tardive dyskin esia u su ally occu rs a ter at least 6 m on th s o startin g a h igh -
p oten cy an tip sych otic an d is b est treated by ch an gin g to a low-p oten cy or atyp ical agen t;
stop p in g th e an tip sych otic m ed ication will exacerbate th e sym p tom s.
5. The answer is B. 6. The answer is E. High body tem p eratu re an d blood p ressu re an d
m u scu lar rigidity in d icate th at th e p atien t h as d evelop ed an an tip sych otic m edication
sid e e ect kn own as n eu rolep tic m align an t syn drom e (see also an swer to Qu estion 1).
Neu rolep tic m align an t syn drom e is seen m ost com m on ly with h igh -p oten cy an tip sych otic
treatm en t an d is b est relieved by stop p in g th e an tip sych otic m edication , p rovidin g m edical
su p p ort, an d adm in isterin g d an trolen e, a m u scle relaxan t. A ter recoverin g rom th is li e-
th reaten in g con dition , th e p atien t can b e switch ed to an atyp ical agen t sin ce th ey are less
likely th an h igh -p oten cy agen ts su ch as h alop eridol to cau se th is dan gerou s side e ect.
7. The answer is D. Com bin ation s o tram adol (Ultram ) a seroton ergic an algesic with SSRIs such
as luoxetin e can lead to th e sym p tom s th is p atien t shows, that is, the seroton in syn drom e.
Opioids such as oxycodon e an d h ydrocodon e an d m ood stabilizers su ch as gabap en tin or
ibu p ro en are un likely to p roduce this syn drom e wh en com bin ed with an SSRI.
8. The answer is D. Th e m ost e ective p h arm acological treatm en t or th is p atien t wh o h as
ob sessive–com p u lsive d isorder is an an tidep ressan t, p articu larly a selective seroton in
reu p take in h ibitor (see Ch ap ter 13). An tip sych otics, an tian xiety agen ts, an d lith iu m are n ot
as ap p rop riate as an an tid ep ressan t or th is p atien t.
9. The answer is C. Th e d octor d ecid es to give th is p atien t lu oxetin e becau se, wh en
com p ared to a h eterocyclic an tidep ressan t, SSRIs su ch as lu oxetin e h ave ewer side e ects.
Heterocyclics an d SSRIs h ave equ al e icacy, equ ivalen t sp eed o action , an d equ ivalen t
len gth o action . Neith er SSRIs n or h eterocyclics are likely to lead to addiction .
184
Chapter 16 Biologic Therapies: Psychopharmacology 185
10. The answer is D. Th e b est ch oice o an tian xiety agen t or a 40-year-old p atien t
with gen eralized an xiety disorder an d a h istory o BZ addiction is bu sp iron e, a
n on ben zodiazep in e with very low addiction p oten tial. Ben zodiazep in es su ch as
lu razep am , clon azep am , an d ch lordiazep oxide h ave h igh er addiction p oten tial th an
bu sp iron e. Bu p rop ion is an an tid ep ressan t, wh ich is also u sed or sm okin g cessation .
Zolp id em is a n on ben zod iazep in e sleep agen t.
11. The answer is A. Zalep lon , a n on ben zodiazep in e sleep agen t, is th e best ch oice to aid
sleep on an overn igh t ligh t. Ben zod iazep in es h ave h igh er add iction p oten tial th an agen ts
su ch as zalep lon . Bu sp iron e h as little ad d iction p oten tial b u t d oes n ot cau se sed ation
an d, in an y case, takes weeks to work. Bu p rop ion is an an tidep ressan t agen t an d is
n on sed atin g.
12. The answer is E. Becau se it is lon g actin g an d h as relatively low addiction p oten tial or a
BZ, ch lordiazep oxide is th e an tian xiety agen t m ost com m on ly u sed to treat th e an xiety an d
agitation associated with th e in itial stages o alcoh ol with drawal.
13. The answer is A. O th e listed agen ts, BZs su ch as d iazep am are m ost likely to cau se
add iction . An tip sych otics su ch as h alop eridol, an tidep ressan ts su ch as lu oxetin e, m ood
stab ilizers su ch as lith iu m , an d n on b en zod iazep in es su ch as b u sp iron e (see also an swer to
Qu estion 10) h ave little or n o ad d iction p oten tial.
14. The answer is B. Th e m ost ap p rop riate n ext step is to recom m en d a cou rse o
electrocon vu lsive th erapy (ECT) or th is elderly, severely dep ressed p atien t. ECT is a
sa e, ast, e ective treatm en t or m ajor d ep ression . Diazep am , lith iu m , bu sp iron e, an d
p sych oth erapy will n ot be e ective as ECT in relievin g th is p atien t’s su icidal dep ression
qu ickly.
15. The answer is E. Th e an tip sych otic agen t th at th is p atien t is m ost likely to be takin g
is clozap in e. Like oth er atyp ical agen ts, clozap in e is m ore e ective again st n egative
sym p tom s (e.g., with d rawal) th an trad ition al agen ts su ch as h alop eridol. However,
clozap in e is also is m ore likely to cau se seizu res an d agran u locytosis th an tradition al
agen ts or oth er atyp icals, su ch as risp eridon e an d olan zap in e.
16. The answer is E. 17. The answer is A. Th is p atien t’s good em p loym en t an d relation sh ip
h istory su ggest th at h is p sych otic sym p tom s are an acu te m an i estation o a m an ic
ep isode. Wh ile th e m ost e ective im m ediate treatm en t or th is p atien t is a ast-actin g,
h igh -p oten cy an tip sych otic agen t, su ch as h alop eridol, to con trol h is h allu cin ation s an d
d elu sion s, lith iu m , wh ich takes 2–3 weeks to work, wou ld be m ore e ective or lon g-term
m ain ten an ce. Flu oxetin e, am itrip tylin e, an d bu sp iron e are less ap p rop riate p rim ary
treatm en ts or th is bip olar p atien t.
18. The answer is F. In con trast to m ost an tidep ressan t agen ts, wh ich are associated with
weigh t gain , lu oxetin e (Prozac) is associated with som e weigh t loss. Th u s, it is th e m ost
ap p rop riate an tidep ressan t agen t or a p atien t wh o is ear u l o gain in g weigh t.
19. The answer is C. Trazodon e is th e agen t m ost likely to cau se p riap ism in th is p atien t.
20. The answer is E. Am oxap in e h as an tid op am in ergic action an d , th u s, is th e agen t m ost
likely to cau se gyn ecom astia as well as p arkin son ian sym p tom s in th is p atien t.
21. The answer is A. SNRIs m ay work m ore q u ickly (e.g., in 2-3 weeks) th an oth er
an tid ep ressan ts an d , as su ch , ven la axin e is a good ch oice or rap id relie o d ep ressive
sym p tom s in th is you n g wom an .
22. The answer is C. Trazadon e n ot on ly can cau se p riap ism (see also an swer to Qu estion 19)
bu t also is h igh ly sedatin g. It is th u s o ten u sed in p atien ts wh o h ave dep ression with
in som n ia.
23. The answer is C. Prolactin is th e h orm on e resp on sible or galactorrh ea, lu id disch arge
rom th e n ip p les. Galactorrh ea is m ore com m on with th e u se o low-p oten cy an tip sych otic
agen ts.
186 BRS Behavioral Science
24. The answer is B. Th is p atien t is sh owin g eviden ce o p seu dop arkin son ism , a n eu rologic
sid e e ect cau sed by excessive blockad e o p ostsyn ap tic dop am in e recep tors du rin g
treatm en t with h igh -p oten cy an tip sych otics, su ch as h alop eridol. Becau se dop am in e
n orm ally su p p resses acetylch olin e activity, givin g th e p atien t an an tich olin ergic agen t
(e.g., ben ztrop in e) will serve to in crease d op am in ergic activity an d relieve th e p atien t’s
sym p tom s. An tian xiety agen ts su ch as b en zod iazep in es can b e u sed as ad ju n cts
to an tich olin ergics, bu t an tidep ressan ts an d lith iu m are n ot e ective or reversin g
p arkin son ian sym p tom s cau sed by an tip sych otics.
25. The answer is E. TCAs su ch as im ip ram in e cau se sin u s tach ycardia, lat T waves, p rolon ged
QT in terval, an d dep ressed ST segm en ts. Bu p rop ion , lu oxetin e, lorazep am , an d valp roic
acid are less likely to cau se th ese cardiovascu lar e ects.
26. The answer is C. Becau se o h er weigh t gain , typ e 2 diabetes, an d cardiovascu lar p roblem ,
th e best ch oice o atyp ical an tip sych otic agen t or th is p atien t n ow is arip ip razole.
Clozap in e an d olan zap in e carry h igh risk an d zip rasid on e an d arip ip razole carry low risk
or weigh t gain an d diabetes. However, zip rasidon e p rolon gs th e QT in terval an d so sh ou ld
be avoid ed in th is p atien t.
27. The answer is E. Metoclop ram id e (Reglan ), a gastric m otility agen t an d an tiem etic, is o ten
u sed to con trol n au sea an d vom itin g in can cer p atien ts receivin g ch em oth erapy. It h as
an tidop am in ergic p rop erties an d can cau se acu te dyston ic reaction s su ch as are occu rrin g
in th is p atien t. Man agem en t in clu des stop p in g th e m etoclop ram id e an d p rovid in g an
an tich olin ergic agen t, su ch as ben ztrop in e, or an an tih istam in e, su ch as dip h en h ydram in e,
b oth o wh ich are u su ally given in in tram u scu lar orm or im m ediate e ect. Asp irin ,
d igoxin , eryth rom ycin , an d lu oxetin e are u n likely to cau se dyston ic reaction s.
28. The answer is B. Th is p atien t wh o is slowed down an d h as a in e restin g trem or o
h is u p p er extrem ities an d sti n ess is sh owin g eviden ce o an tip sych otic-in du ced
p arkin son ism , o ten a sid e e ect o h igh d oses o h igh -p oten cy an tip sych otics su ch
as h alop erid ol. Ben ign essen tial trem or an d Parkin son’s disease are n ot related to
an tip sych otic m ed ication . Alth ou gh th ey can b oth be side e ects o h alop eridol treatm en t,
n eu rolep tic m align an t syn d rom e an d tard ive d yskin esia are ch aracterized by h igh ever
an d ab n orm al ton gu e an d acial m ovem en ts, resp ectively.
29. The answer is B. 30. The answer is D. The m ost app rop riate resp on se or th e p hysician
is to tell the patien t that the risk or depression is greater a ter than be ore delivery an d
that depression durin g pregn an cy can o ten be sa ely treated. Most an tidepressan ts are in
pregn an cy category C but two, bup rop ion an d m aprotilin e, are in category B. Discussin g
di eren tial suicide rates is n ot a h elp ul in terven tion . In an y case, the su icide rate is lower
or wom en who are pregn an t than or those who are n ot pregn an t. While ECT is quite sa e in
pregn an cy, p sychop h arm acology is less in vasive an d usually p re erred. I the doctor decides
to p rescribe an SSRI or th is patien t durin g p regn an cy, paroxetin e (A category D agen t)
sh ould be avoided.
31. The answer is D. Th e d ru g o ch oice in th e treatm en t o bu lim ia is an SSRI su ch as
lu oxetin e. Th e action o SSRIs is seroton in reu p take in h ibition .
32. The answer is D. Th is p atien t wh o b ecam e ill at a p izza p arty is m ost likely to b e takin g
tran ylcyp rom in e, a m on oam in e oxidase in h ibitor (MAOI). Th ese agen ts can cau se a
h yp erten sive crisis i certain oods (e.g., aged ch eese, sm oked m eats, beer, an d win e) are
in gested. A p atien t wh o eats in an u n am iliar p lace (e.g., a p arty) m ay u n wittin gly in gest
orbidden oods. Th is p atien t ate p izza th at p robably con tain ed aged Parm esan ch eese
an d d ran k p u n ch th at p rob ab ly con tain ed red win e. Th is resu lted in a h yp erten sive crisis
(e.g., elevated b lood p ressu re, sweatin g, h eadach e, an d vom itin g). Flu oxetin e, lith iu m ,
n ortrip tylin e, an d h alop eridol do n ot in teract n egatively with ood.
c ha pte r
17 Psych ological Th erap ies
C. Peop le wh o are ap p rop riate or u sin g p sych oan alysis an d related th erap ies sh ou ld h ave th e
ollowin g ch aracteristics:
1. Are you n ger th an 40 years o age.
2. Are in telligen t an d n ot p sych otic.
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188 BRS Behavioral Science
3. Have good relation sh ip s with oth ers (e.g., n o eviden ce o an tisocial or borderlin e p erson -
ality disorder).
4. Have a stab le li e situ ation (e.g., n ot be in th e m idst o divorce).
5. Have th e tim e an d m on ey to sp en d on treatm en t.
D. In psychoanalysis , p eop le receive treatm en t four to five times weekly for 3–4 years ; related
th erap ies are brie er an d m ore direct (e.g., brie dyn am ic p sych oth erapy is lim ited to
12–40 weekly session s).
B. In con trast to p sych oan alysis an d related th erap ies, th e p erson’s h istory an d unconscious
conflicts are irrelevant an d th u s are n ot exam in ed in beh avioral th erap ies.
C. Ch aracteristics o sp eci ic b eh avioral th erap ies (e.g., system atic desen sitization , aversive
con d ition in g, lood in g an d im p losion , token econ om y, bio eedback, an d cogn itive/ beh av-
ioral th erapy) can be ou n d in Table 17.1.
Systematic Desensitization
Management of phobias (irrational In the past, through the process of classical conditioning (see Chapter 7), the
fears; see Chapter 13) person associated an innocuous object with a fear-provoking stimulus until the
innocuous object became frightening
In the present, increasing doses of the fear-provoking stimulus are paired with a
relaxing stimulus to induce a relaxation response
Because one cannot simultaneously be fearful and relaxed (reciprocal inhibition), the
person shows less anxiety when exposed to the fear-provoking stimulus in the future
Aversive Conditioning
Management of paraphilias Classical conditioning is used to pair a maladaptive but pleasurable stimulus with an
(e.g., pedophilia) or addictions aversive or painful stimulus (e.g., a shock) so that the two become associated.
(e.g., smoking) The person ultimately stops engaging in the maladaptive behavior because it
automatically provokes an unpleasant response
Flooding and Implosion
Management of phobias The person is exposed to an actual (flooding) or imagined (implosion) overwhelming
dose of the feared stimulus.
Through the process of habituation (see Chapter 7), the person becomes
accustomed to the stimulus and is no longer afraid
Token Economy
To increase positive behavior in a person Through the process of operant conditioning (see Chapter 7), desirable behavior
who is disorganized (e.g., psychotic) (e.g., shaving, hair combing) is reinforced by a reward or positive reinforcement
or has severe autism spectrum (e.g., the token)
disorder or intellectual disability The person increases the desirable behavior to gain the reward
Biofeedback
To manage hypertension, Raynaud’s Through the process of operant conditioning, the person is given ongoing
disease, migraine and tension physiologic information (e.g., blood pressure measurement), which acts as
headaches, chronic pain, fecal reinforcement (e.g., when blood pressure drops)
incontinence, and temporomandibular The person uses this information along with relaxation techniques to mentally control
joint pain visceral changes (e.g., heart rate, blood pressure, smooth muscle tone)
Cognitive/Behavioral Therapy (CBT)
To manage mild to moderate depression, Weekly, for 15–25 wk, the person is helped to identify distorted, negative thoughts
somatic symptom disorders, eating about him- or herself
disorders The person replaces these negative thoughts with positive, self-assuring thoughts,
and symptoms improve
Dialectal behavioral therapy is a form of CBT which is particularly useful for
borderline personality disorder
Chapter 17 Psychological Therapies 189
A. Group therapy
1. Groups with therapists
a. Grou p s o u p to ab ou t eigh t p eop le with a com m on p roblem or n egative li e exp eri-
en ce u su ally m eet weekly or 1–2 h ou rs; sh arin g th e th erap ist redu ces cost.
b. Mem bers o th e grou p p rovide th e op p ortu n ity to exp ress eelin gs as well as feedback,
support, an d friendship to each oth er.
c. The therapist has little input. He or sh e acilitates an d observes th e m em bers’ in terp er-
son al in teraction s.
2. Leaderless groups
a. In a leaderless grou p, no one person is in authority.
b. Mem bers o th e grou p p rovid e each oth er with support and practical help or a sh ared
p roblem (e.g., alcoh olism , loss o a loved on e, a sp eci ic illn ess).
c. Twelve-step grou p s like Narcotics Anonymous (NA) an d Overeaters Anonymous (OA) are
b ased on th e Alcoholics Anonymous (AA) leaderless grou p m odel (see Ch ap ter 9).
B. Family therapy
1. Family systems theory
a. Fam ily th erapy is based on th e am ily system s idea th at p sych op ath ology in on e am ily
m em b er (i.e., th e id en ti ied p atien t) re lects dysfunction of the entire family system.
b. Becau se all m em bers o th e am ily cau se beh avioral ch an ges in oth er m em bers,
the family ( not the identified patient) is really the patient.
c. Strategies o am ily th erapy in clu d e id en ti yin g dyads (i.e., su b system s b etween two
am ily m em bers), triangles (i.e., d ys u n ction al allian ces b etween two am ily m em bers
again st a th ird m em ber), an d boundaries (i.e., b arriers between su b system s) th at m ay
be too rigid or too p erm eab le.
2. Specific techniques are u sed in am ily th erapy.
a. Mutual accommodation is en cou raged. Th is is a p rocess in wh ich am ily m em bers work
toward m eetin g each oth er’s n eeds.
b. Normalizing boundaries b etween su bsystem s an d red u cin g th e likelih ood o trian gles is
en cou raged .
c. Redefining “blame” (i.e., en cou ragin g am ily m em bers to recon sider th eir own resp on -
sib ility or p roblem s) is an oth er im p ortan t tech n iqu e.
1. A 30-year-old m an who is a raid to ride 4. Ten arth ritis p atien ts m eet on ce p er week
in an elevator is p u t in to a relaxed state to talk with each oth er an d to in orm each
an d th en sh own a f lm o p eople en terin g oth er o n ew d evices an d services to h elp
elevators in a h igh -rise bu ildin g. Th is m eth od disabled p eop le with everyday tasks. Th is
o m an agem en t is based p rim arily on type o th erapy is best described as
(A) recip rocal in h ibition (A) grou p th erapy
(B) classical con d ition in g (B) leaderless grou p th erapy
(C) aversive con d ition in g (C) brie dyn am ic p sych oth erapy
(D) op eran t con d ition in g (D) am ily th erapy
(E) stim u lu s gen eralization (E) su p p ortive th erapy
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192 BRS Behavioral Science
8. The answer is G. Th e m an agem en t tech n iqu e d escrib ed h ere is cogn itive/ beh avioral
th erapy, a sh ort-term beh avioral m an agem en t tech n iqu e in wh ich th e p erson is in stru cted
to rep lace each n egative th ou gh t with a p ositive m en tal im age.
9. The answer is C. Th e m an agem en t tech n iqu e described h ere is aversive con dition in g, in
wh ich a m aladap tive b u t p leasu rab le stim u lu s ( or th is m an , sexu al in terest in ch ildren ) is
p aired with p ain u l stim u lu s (e.g., a sh ock) so th at th e two becom e associated. Th e p erson
n ow associates sexu al in terest in ch ild ren with p ain an d stop s th is m aladap tive beh avior.
10. The answer is F. Th e m an agem en t tech n iqu e d escribed h ere is system atic d esen sitization .
In th is exam p le, th e ch ild m ad e an erron eou s n egative association between dogs an d p ain
wh en sh e was in ju red in th e p resen ce o th e dog. In system atic desen sitization , in creasin g
doses o th e righ ten in g stim u lu s (e.g., d ogs) are p aired with a relaxin g stim u lu s (e.g.,
th e avorite CD) to p rovoke a relaxation resp on se in situ ation s in volvin g th e righ ten in g
stim u lu s. Later in treatm en t, th is ch ild will rem ain in a relaxed state wh en sh e is exp osed to
a livin g d og.
11. The answer is C. Th e m ajor reason th at p atien ts wh o cou ld ben e it rom p sych oan alytically
orien ted p sych oth erapy do n ot receive it is th at th ey o ten believe it is exp en sive an d
tim e con su m in g. Less com m on ly, p eop le d o n ot wan t to reveal th eir h istories an d
p erson al p roblem s to stran gers, are n ot in terested in exp lorin g th eir ch ildh oods, or eel
u n com ortable in th e th erap eu tic settin g.
Th e Fam ily, Cu ltu re,
c ha pte r
18 an d Illn ess
B. Types of families
1. Th e traditional nuclear family in clu des a m oth er, a fath er, an d dep en den t ch ildren (i.e.,
u n der age 18) livin g togeth er in on e h ou seh old.
2. Oth er typ es of fam ilies in clu de coh abitin g h eterosexu al fam ilies an d gay-p aren t fam ilies
an d sin gle-p aren t fam ilies.
3. Th e extended family in clu d es fam ily m em bers, su ch as gran d p aren ts, au n ts, u n cles, an d
cou sin s, wh o live ou tsid e th e h ou seh old.
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196 BRS Behavioral Science
3. A good m arriage is an im p ortan t p red ictor of h ealth . Married p eop le are mentally an d
physically healthier an d h ave h igh er self-esteem th an u n m arried p eop le.
4. Ap p roxim ately 60% of children live in fam ilies with two working parents ; on ly abou t 20% of
children live in th e “traditional family,” in wh ich th e fath er works ou tsid e of th e h om e an d
th e m oth er is a fu ll-tim e h om em aker.
5. Raisin g ch ild ren is exp en sive. Th e total cost of raisin g a ch ild to age 17 in th e Un ited
States is cu rren tly m ore th an $250,000. Postsecon d ary ed u cation greatly in creases th is
figu re.
C. Acculturative stress
1. Th e con cep t of accu ltu rative stress is u sed as an altern ative to th e term “cu ltu re sh ock.” It
is an emotional response , in volvin g psychiatric symptoms as well as in creased su scep tibility
to disease, wh ich is related to geograp h ic relocation an d th e n eed to adap t to u n fam iliar
social an d cu ltu ral su rrou n d in gs. Accu ltu rative stress is redu ced wh en grou p s of im m i-
gran ts of a p articu lar cu ltu re live in th e sam e geograp h ic area.
2. Young immigrant men ap p ear to b e at higher risk for accu ltu rative stress, in clu din g sym p -
tom s su ch as p aran oia an d d ep ression , th an oth er sex an d age grou p s. Th is is tru e in p art
b ecau se:
a. You n g m en lose the most status on leavin g th eir cu ltu re of origin .
b. Un like oth ers in th e grou p wh o can stay at h om e am on g fam iliar p eop le, you n g m en
often m u st get ou t in to th e n ew cu ltu re an d earn a livin g.
198 BRS Behavioral Science
B. Hispanic/Latino Americans
1. Overview
a. With abou t 17.1% of th e p op u lation , Hisp an ic Am erican s (m ain ly in clu din g p eop le
from Sp an ish -sp eakin g region s of Latin Am erica, i.e., Latin os) are n ow th e largest
minority group in th e Un ited States.
b. As a grou p, Latin os p lace great valu e on th e n u clear fam ily an d on nuclear families with
many children.
c. Respect for the elderly is im p ortan t. You n ger p eop le are exp ected to care for elderly
fam ily m em bers, to protect elderly relatives from negative medical diagnoses , an d, often ,
to m ake m ed ical d ecision s con cern in g th e care of elderly relatives.
d. Am on g som e Latin os, “hot” and “cold” influences are believed to relate to illn ess.
e. Latin o wom en are less likely to get m am m ogram s an d m ore likely to h ave cervical can -
cer th an are Wh ite Am erican or African Am erican wom en .
2. Two-th irds of all Latin os, esp ecially th ose in th e Sou th west, are of Mexican origin .
3. Th e secon d largest grou p (9.4%) of Latin os is of Puerto Rican origin . Most live in th e
North eastern states.
4. More th an 3.7% of Latin os are of Cuban origin an d live p rim arily in th e Sou th east, esp e-
cially in Florida.
5. Alth ou gh th e exp lan ation is elu sive, as a grou p, Latin os h ave lon ger life exp ectan cies th an
African Am erican s or Wh ite Am erican s (see Figu re 3.1).
C. Asian Americans
1. Abou t 5.3% of th e US p op u lation is Asian Am erican . Th e largest grou p s are Chinese,
Filipino, an d Asian Indian.
2. Oth er Asian Am erican grou p s in clu de th e Vietnamese, Korean, an d J apanese .
Chapter 18 The Family, Culture, and Illness 199
3. Alth ou gh m an y grou p s are assimilated, eth n ic differen ces m ay still resu lt in d ifferen t
resp on ses to illn ess am on g Asian Am erican grou p s.
4. Ch aracteristics of th ese cu ltu res in clu de th e followin g:
a. As in Latin o cu ltu res, ad u lt Asian Am erican ch ild ren show strong respect for an d are
expected to care for their elderly parents , p rotect elderly relatives from n egative m edical
d iagn oses, an d m ake m ed ical d ecision s abou t elderly relatives’ care.
b. Patien ts m ay exp ress em otion al p ain as p h ysical illn ess.
c. In som e Asian Am erican grou p s, th e abdominal–thoracic area , rath er th an th e b rain , is
often th ou gh t to be th e spiritual core of th e p erson . Th u s, th e con cep t of brain death
an d resu ltin g organ tran sp lan t are gen erally n ot well accep ted.
d. Folk remedies in clu de coining (a coin is ru bbed on th e affected area p ressin g a m edi-
cated oil in to th e skin ); in ju ries occu rrin g as a resu lt of u se of su ch rem edies m ay be
m istaken by m edical p erson n el for abu se (see Ch ap ter 20).
e. Certain disorders, for exam p le, gastric cancer, are m ore com m on in Asian s livin g in
th eir n ative cou n tries th an in Asian s livin g in th e Un ited States. For exam p le, rates of
gastric can cer are fou r tim es h igh er in Jap an ese p eop le livin g in Jap an th an in Jap an ese
Am erican s livin g in Los An geles. Cu ltu re-related d ietary factors (e.g., m ore n itrate-rich
foods in Jap an ) m ay h elp exp lain th is differen ce.
1. A 24-year-old m arried Mu slim wom an , 3. Sim ilarly, th e p rin cip al’s best gu ess abou t
who is exp erien cin g severe p elvic p ain , th e p ercen tage of African Am erican stu den ts
is brou gh t to th e em ergen cy room by h er who live with ju st th eir m oth ers is
h u sban d. Wh en in stru cted to disrobe an d (A) <10%
p u t on a h osp ital gown , sh e refu ses u n less (B) 15%–25%
sh e can be assu red th at sh e will be seen by (C) 45%–50%
a fem ale p h ysician . Th e m ost ap p rop riate (D) 50%–60%
statem en t th e m ale em ergen cy room (E) 75%–85%
p h ysician can m ake at th is tim e is
(A) “I will try to locate a fem ale p h ysician bu t 4. Th e p rin cip al’s best gu ess abou t th e
if I can n ot do so, I m u st exam in e you .” p ercen tage of stu den ts wh o are Native
(B) “I am a b oard -certified p h ysician an d Am erican is
am as qu alified as a fem ale doctor to (A) <10%
exam in e an d treat you .” (B) 15%–25%
(C) “I will try to locate a fem ale p h ysician ; (C) 45%–50%
if I can n ot do so, h ow can I h elp you (D) 55%–65%
b e m ore com fortable with m e as you r (E) 75%–85%
d octor?”
(D) “I can n ot h elp you if you will n ot 5. A large exten d ed fam ily im m igrates to th e
coop erate.” Un ited States. Th e p erson in th e fam ily wh o
(E) “Severe p elvic p ain is som etim es life is at h igh est risk for p sych iatric sym p tom s
th reaten in g. I m u st exam in e you after th e m ove is th e
im m ediately.”
(A) 84-year-old great-gran dfath er
(B) 28-year-old u n cle
Questions 2–4
(C) 36-year-old au n t
(D) 10-year-old sister
An elem en tary sch ool in Texas in clu d es ch il-
(E) 55-year-old gran dm oth er
dren from m an y cu ltu res. In fact, th e p rin -
cip al h as discovered th at th e p op u lation of
6. A 12-year-old ch ild is told to write a
th e sch ool directly m irrors th at of th e US
rep ort abou t h is “n u clear fam ily.” To do
p op u lation .
th is task correctly, th e rep ort m u st con tain
in form ation on h is
2. If th e sch ool’s p rin cip al is tryin g to
estim ate h ow m an y of th e sch ool’s stu den ts (A) 84-year-old great-gran dfath er
live in a “trad ition al” fam ily situ ation , h er (B) 28-year-old u n cle
best gu ess is (C) 36-year-old au n t
(D) 10-year-old sister
(A) <10%
(E) 55-year-old gran dm oth er
(B) 15%–25%
(C) 45%–50%
(D) 55%–65%
(E) 75%–85%
200
Chapter 18 The Family, Culture, and Illness 201
14. A 70-yea r-o ld La tin o wo m a n , wh o se (A) “Do you believe th at you r h u sban d is still
h u sb a n d d ied 4 m o n th s a go, ca lm ly tells alive?”
h er p h ysicia n th a t sh e a n d h er h u sb a n d (B) “Do oth er p eop le in th e Latin o
still co m m u n ica te with ea ch o th er. Th e com m u n ity b elieve th at th e livin g
p atien t sh ows n o evid en ce o f a th o u gh t an d th e dead com m u n icate with each
d isord er, a n d h er p h ysica l exa m in a tio n oth er?”
is u n rem a rka b le. Wh ich of th e followin g (C) “I wou ld like you to take a m edication
is th e m o st a p p ro p ria te q u estio n o r called risp eridon e for th e n ext few
sta tem e n t fro m th e p h ysicia n a t th is m on th s.”
tim e? (D) “Most p eop le d o n ot th in k th at th ey can
com m u n icate with th e dead .”
(E) “How do you feel wh en you r h u sban d
com m u n icates with you ?”
An swers an d Exp lan ation s
1. The answer is C. Mu slim wom en often p refer to h ave a fem ale p h ysician , p articu larly for
gyn ecological or ob stetrical p roblem s. In th is case, th e p h ysician sh ou ld try to h on or th e
p atien t’s wish es. If th is is n ot p ossible, th e p atien t sh ou ld be con su lted for altern ative
accep table strategies, for exam p le, sh e m ay su ggest h avin g h er h u sb an d or oth er fam ily
m em ber (e.g., h er m oth er) p resen t wh en sh e is exam in ed by th e m ale p h ysician . Tryin g to
im p ress th e p atien t with on e’s creden tials, or frigh ten h er in to adh eren ce are n ot ap p rop ri-
ate or u sefu l strategies (see also Ch ap ter 21).
2. The answer is B. 3. The answer is C. 4. The answer is A. Ap p roxim ately 20% of Am erican
ch ild ren live in a “trad ition al” fam ily situ ation (th e m oth er stays h om e an d th e fath er
works). Ap p roxim ately 49% of African Am erican ch ildren live with ju st th eir m other. Native
Am erican s m ake u p b etween 1% an d 2% of all Am erican s.
5. The answer is B. You n g im m igran t m en , su ch as th e 28-year-old u n cle, are at h igh er risk
for p sych iatric sym p tom s wh en en terin g a n ew cu ltu re th an are an y oth er gen der or age
grou p. Th is is b ecau se th ey lose th e m ost statu s on leavin g th eir old cu ltu re an d becau se,
u n like oth er grou p s th at can stay at h om e am on g th eir fam ilies, you n g m en often m u st get
ou t in to th e n ew cu ltu re to work an d m ake a livin g.
6. The answer is D. Th e “n u clear fam ily” con sists of p aren ts an d dep en den t ch ildren (e.g., th e
b oy’s sister) livin g in on e h ou seh old . Th e great-gran dfath er, u n cle, au n t, an d gran dm oth er
u su ally are p art of th e “exten ded fam ily.”
7. The answer is A. 8. The answer is A. Ab ou t 5% of elderly Am erican s sp en d th eir last years
livin g in a n u rsin g h om e. Elderly Asian Am erican an d Hisp an ic Am erican p eop le are m ore
likely th an An glo-Am erican s to be cared for by th eir adu lt ch ildren rath er th an in a n u rsin g
h om e settin g.
9. The answer is D. Statistically, a m id d le-aged African Am erican p atien t h as a lower likeli-
h ood of su icid e th an a Wh ite Am erican p atien t of th e sam e age. However, wh en com p ared
to Wh ite Am erican p atien ts, African Am erican p atien ts h ave a h igh er likelih ood of stroke,
asth m a, h yp erten sion , an d p rostate can cer as well as h eart d isease, tu b ercu losis, d iab etes,
an d AIDS.
10. The answer is A. In th e Un ited States, it is relatively u n com m on to see a self-su p p ortin g
ad u lt, su ch as th e 34-year-old m ed ical residen t, livin g with h is p aren ts. A 46-year-old m an
livin g with h is wife an d ch ild ren is a com m on livin g situ ation in th e Un ited States; th e
203
204 BRS Behavioral Science
d ivorce rate is h igh , b u t m ost p eop le in th eir 40s are m arried, n ot sin gle or divorced. It is
also relatively com m on to see an 85-year-old wom an livin g with fam ily m em bers.
11. The answer is C. Of th e listed factors, th eir p aren ts’ h istories of divorce are a risk factor for
divorce for th is cou p le. Teen age m arriages, sh ort cou rtsh ip, an d d ifferen ces in socioeco-
n om ic an d religiou s b ackgrou n ds also p u t cou p les at risk for divorce.
12. The answer is B. Th e m ost likely exp lan ation for th is d ifferen ce b etween th e twin s (i.e.,
th e on e in Jap an h as an d th e on e in th e Un ited States h as n ot been diagn osed with gastric
can cer) is th at en viron m en tal factors are likely to p lay a role in th e develop m en t of gastric
can cer. If on ly gen etic factors were in volved , b oth wom en wou ld be likely to h ave th e dis-
ease. A diet h igh in n itrates su ch as th at eaten in Jap an is a risk factor for gastric can cer, b u t
it is n ot clear th at th is is th e on ly en viron m en tal factor to wh ich th e two wom en are differ-
en tially exp osed. Th ere is n o reason to b elieve th at testin g tech n iqu es for gastric can cer are
differen t in Jap an an d in th e Un ited States or th at exercise can p reven t gastric can cer.
13. The answer is D. As lon g as th e treatm en t will n ot h arm th e p atien t, th e p h ysician sh ou ld
try to work in con ju n ction with th e h ealer. Sin ce in th is case th e folk rem edy is in n ocu ou s,
th e p atien t can con tin u e u sin g it alon g with tradition al m edical m an agem en t (e.g., an an ti-
h yp erten sive agen t). Th e p h ysician sh ou ld n ot try to sep arate th e p atien t from h is cu ltu ral
beliefs by refu sin g to treat h im u n til h e stop s u sin g th e folk h ealer, qu estion in g th e h ealer’s
train in g in m odern m edicin e, or dou btin g th e valu e of th e recom m en ded rem edy. It cou ld
be d an gerou s to delay th e p atien t’s treatm en t for a m on th to p rove to h im th at eatin g corn
will n ot h elp h is con dition .
14. The answer is B. Th is Latin o p atien t wh o rep orts th at sh e com m u n icates with h er d ead
h u sban d is p robably n ot exp erien cin g a delu sion (i.e., a false belief n ot sh ared by oth ers
[see Table 11.1]). Rath er, sh e is m ost likely to be rep ortin g a cu ltu ral p h en om en on based on
th e belief, in som e Latin o cu ltu res, th at th e lin e between th e dead an d th e livin g is blu rred.
As fu rth er eviden ce th at th is is n ot a d elu sion th e p atien t sh ows n o eviden ce of a th ou gh t
disord er. Th u s, sh e d oes n ot n eed to take an an tip sych otic su ch as risp eridon e. Th ere is
n o evid en ce th at sh e eith er b elieves h er h u sb an d is alive or th at sh e is distu rbed by th ese
exp erien ces.
c ha pte r
19 Sexu ality
I. SEXUAL DEVELOPMENT
A. Prenatal physical sexual development
1. Di eren tiation o th e gonads is d ep en den t on th e p resen ce or ab sen ce o th e Y chromo-
some , wh ich con tain s th e testis-determ in in g actor gen e.
2. Th e an drogen ic secretion s o th e etal testes d irect th e di eren tiation o male in tern al an d
extern al gen italia.
a. In the absence of androgens du rin g p ren atal li e, in tern al an d extern al genitalia are
female .
b. In androgen insensitivity syndrome ( orm erly testicu lar em in ization ), desp ite an XY
genotype an d testes th at secrete an d rogen , a gen etic de ect p reven ts th e body cells rom
resp on din g to an d rogen , resu ltin g in a em ale p h en otyp e. At p u b erty, th e d escen d in g
testes m ay ap p ear as lab ial or in gu in al m asses.
c. In th e p resen ce o excessive adren al an drogen secretion p ren atally (congenital virilizing
adrenal hyperplasia), th e gen italia o a gen etic em ale are m ascu lin ized an d th e ch ild
m ay b e visu ally id en ti ied in itially as m ale.
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206 BRS Behavioral Science
Gender identity Sense of self as being male or Differential exposure to May not agree with physiological
female prenatal sex hormones sex (i.e., gender dysphoria)
Gender role Expression of one’s gender Societal pressure to May not agree with gender identity
identity in society conform to sexual norms or physiological sex (e.g., choice
of opposite gender’s clothing)
Sexual Persistent and unchanging Differential exposure to Homosexuality and bisexuality are
orientation preference for people of the prenatal sex hormones considered normal variants of
same sex (homosexual), the Genetic influences sexual expression
opposite sex (heterosexual),
or no preference (bisexual)
for love and sexual
expression
2. Gender identity, gender role , an d sexual orientation (Table 19.1) also m ay be a ected by
p ren atal exp osu re to gon adal h orm on es.
a. In d ividu als with gender dysphoria (tran ssexu al or tran sgen der in dividu als) h ave a p er-
vasive p sych ological eelin g o bein g born in to th e body o th e wron g sex desp ite a
b od y orm typ ical o th eir p h ysiological sex.
b. Sch ool-age ch ildren with gen der d ysp h oria p re er to dress like an d h ave p laym ates o
th e op p osite sex. Sin ce gender identity is permanent, th e m ost e ective m an agem en t o
th is situ ation is to h elp p aren ts accep t th e ch ild as h e or sh e is.
c. In adu lth ood, th ese in dividu als com m on ly take th e horm on es o their p re erred gen der
an d h ave p lastic su rgery p rocedu res in order to better assu m e th at gen der role; som e
m ay also seek su rgery to ch an ge th eir gen ital sex.
t a b l e 19.2 Characteristics of the Stages of Sexual Response Cycles in Men and Women
Excitement Stage
Penile erection Clitoral erection Increased pulse, blood pressure, and
Labial swelling respiration
Vaginal lubrication Nipple erection
Tenting effect (rising of the uterus in
the pelvic cavity)
Plateau Stage
Increased size and upward Contraction of the outer third of the Further increase in pulse, blood pressure,
movement of the testes vagina, forming the orgasmic and respiration
Secretion of a few drops of platform (enlargement of the upper Flushing of the chest and face (the “sex
sperm-containing fluid third of the vagina) flush”)
Orgasm Stage
Forcible expulsion of seminal Contractions of the uterus and vagina Contractions of the anal sphincter
fluid Further increase in pulse, blood pressure,
and respiration
Resolution Stage
Refractory, or resting, period Little or no refractory period Muscle relaxation
(length varies by age and Return of the sexual, muscular, and
physical condition) when cardiovascular systems to the
restimulation is not possible prestimulated state over 10–15 min
levels in adu lth ood are in distin gu ish able rom th ose o h eterosexu al p eop le o th e
sam e b iological sex.
b. Evid en ce or in volvem en t o genetic factors in clu des m arkers on th e X ch rom osom e
an d h igh er con cord an ce rate in m on ozygotic th an in dizygotic twin s.
c. Social factors , su ch as early sexu al exp erien ces, are not associated with th e etiology o
h om osexu ality.
d. Hom osexu ality is a n orm al varian t o sexu al exp ression . Becau se it is n ot a dys u n ction ,
no treatment is n eed ed . Peop le wh o are u n com ortab le with th eir sexu al orien tation
m ay b en e it rom p sych ological in terven tion to h elp th em becom e m ore com ortable.
2. Occurrence
a. By m ost estim ates, at least 5%–10% of the population h as an exclu sively h om osexu al
sexu al orien tation ; m an y m ore p eop le h ave h ad at least on e sexu al en cou n ter leadin g
to arou sal with a p erson o th e sam e sex.
b. Th ere are no significant ethnic differences in th e occu rren ce o h om osexu ality.
c. Man y p eop le with gay an d lesb ian sexu al orien tation s h ave exp erien ced h eterosexu al
sex an d h ave h ad ch ild ren .
of medication (e.g., selective seroton in reu p take in h ibitors [SSRIs] can cau se delayed
orgasm ), substance use (e.g., alcoh ol u se can cau se erectile d isorder), an d hormonal or
neurotransmitter alterations .
b. Psychological causes in clude curren t relation ship problem s, stress, depression , and an xi-
ety (e.g., guilt, per orm an ce pressure). In m en with erectile disorder, the presen ce o m orn -
in g erection s, erection s durin g m asturbation, or erection s durin g rapid eye m ovem en t
(REM) sleep suggests a psychological rather than a physical cause o erectile disorder.
2. Dys u n ction s m ay always h ave b een p resen t (lifelong), or, m ore com m on ly, th ey occu r
a ter an in terval wh en u n ction h as been typ ical (acquired).
B. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) classifications o
sexu al d ys u n ction s
1. Th e sexu al desire an d arou sal disorders are male hypoactive sexual desire disorder, female
sexual interest/arousal disorder, an d erectile disorder (disorders o th e excitem en t an d p la-
teau p h ases).
2. Th e orgasm ic disorders are delayed ejaculation, premature ejaculation, an d female orgas-
mic disorder.
3. Genitopelvic pain/penetration disorder is diagn osed wh en th e sym p tom s are n ot cau sed by
a gen eral m ed ical con dition .
4. Table 19.3 sh ows ch aracteristics o th e sexu al dys u n ction s.
C. Management
1. Th e p h ysician m u st understand th e p atien t’s sexu al p rob lem be ore p roceed in g with treat-
m en t (e.g., clari y wh at a p atien t m ean s wh en h e says, “I h ave a p roblem with sex.”).
2. Th e p h ysician sh ou ld not assume anything abou t a p atien t’s sexu ality (e.g., a m iddle-aged
m arried m ale p atien t m ay b e h avin g an extram arital h om osexu al relation sh ip ).
3. Th ere is a growin g ten den cy or p h ysician s to manage the sexual problems of heterosexual
and homosexual patients rath er th an to re er th ese p atien ts to sex th erap ists.
4. Man agem en t o sexu al p rob lem s m ay b e b eh avioral, m edical, or su rgical.
5. Behavioral management techniques
a. In sensate-focus exercises (u sed to m an age sexu al d esire, arou sal, an d orgasm ic disor-
d ers), th e in divid u al’s awaren ess o tou ch , sigh t, sm ell, an d sou n d stim u li are in creased
Disorder Characteristics
du rin g sexu al activity, an d p sych ological p ressu re to ach ieve an erection or orgasm is
decreased .
b. In th e “squeeze“ technique , wh ich is u sed to m an age premature ejaculation, th e m an is
tau gh t to iden ti y th e sen sation th at occu rs ju st be ore th e em ission o sem en . At th is
m om en t, th e m an asks h is p artn er to exert p ressu re on th e coron al ridge o th e glan s
on b oth sid es o th e p en is u n til th e erection su b sides, th ereby d elayin g ejacu lation .
c. Relaxation techniques, hypnosis , an d systematic desensitization (see Ch ap ter 17) are
u sed to redu ce an xiety associated with sexu al p er orm an ce.
d. Masturbation m ay b e recom m en ded to h elp th e p erson learn wh at stim u li are m ost
e ective or ach ievin g arou sal an d orgasm .
6. Medical and surgical management
a. Becau se th ey delay orgasm , SSRIs (e.g., lu oxetin e) can b e u sed to m an age premature
ejaculation.
b. Systemic administration of opioid antagonists (e.g., n altrexon e) an d vasodilators (e.g.,
yoh im b in e) h ave b een u sed to m an age erectile disorder.
c. In erectile disorder, sildenafil citrate (Viagra) an d related agen ts:
(1) Act by in h ib itin g th e en zym e (p h osp h od iesterase typ e 5 [PDE5]) th at destroys
cyclic gu an osin e m on op h osp h ate (cGMP), a vasodilator secreted in th e p en is with
sexu al stim u lation . Th is in h ib ition lead s to slowin g o th e d egrad ation o cGMP
an d p ersisten ce o th e erection .
(2) Have side e ects th at in clu de b lu e-colored vision .
(3) Are con train d icated in m en wh o take n itrates.
(4) In clu de n ewer PDE5 in h ibitors with greater p oten cy an d selectivity th an silden a il,
or exam p le, vardenafil (Levitra, Nu viva) an d tadalafil (Cialis).
d. Intracorporeal injection of vasodilators (e.g., p ap averin e, p h en tolam in e) an d im p lan ta-
tion o prosthetic devices are also u sed to m an age erectile disorder.
e. Apomorphine hydrochloride (Up rim a) in creases sexu al in terest an d erectile u n ction by
in creasin g d op am in e availability in th e brain . It is dissolved su blin gu ally, an d its side
e ects in clu d e p ostu ral h yp oten sion an d syn cop e ( ain tin g).
Exhibitionistic Revealing one’s genitals to unsuspecting women so that they will be shocked
Fetishistic Contact with inanimate objects (e.g., women’s shoes, rubber sheets)
Frotteuristic Rubbing the penis against a clothed woman who is not consenting and not aware
(e.g., on a crowded train)
Necrophilistic Engaging in sexual activity with corpses
Pedophilic Engaging in fantasies or actual behaviors with children under age 14 y, of the opposite
or same sex; person is at least age 16 y and ≥ 5 y older than the child; is the most
common paraphilia
Sexual masochism Receiving physical pain or humiliation
Sexual sadism Giving physical pain or humiliation
Transvestic Wearing women’s clothing, particularly underclothing (exclusive to heterosexual men)
Voyeuristic Secretly watching other people (often by using binoculars or cameras) undressing or
engaging in sexual activity
Other specified, e.g., zoophilia Preferentially engaging in sexual activity with animals
210 BRS Behavioral Science
B. Diabetes
1. On e-qu arter to on e-h al o diabetic m en (m ore com m on ly older p atien ts) h ave erectile
disorder. Orgasm an d ejacu lation are less likely to be a ected.
2. Th e m ajor cau ses o erectile d isorder in m en with diabetes are vascular changes an d dia-
betic neuropathy cau sed by dam age to blood vessels an d n erve tissu e in th e p en is as a
resu lt o hyperglycemia .
a. Erectile p rob lem s gen erally occu r several years a ter diabetes is diagn osed bu t may be
the first symptom o th e d isease.
b. Poor metabolic control o d iab etes is related to in creased in ciden ce o sexu al p roblem s.
c. Sild en a il citrate an d related agen ts o ten are e ective in diabetes-related erectile
disord ers.
d. Alth ou gh p h ysiologic cau ses are m ost im p ortan t, psychological factors su ch as ear o
sexu al “ ailu re” also m ay in lu en ce erectile p roblem s associated with diabetes.
C. Drugs of abuse
1. Alcohol and marijuana in crease sexu ality in th e sh ort term by decreasin g p sych ological
in h ib ition s.
a. With lon g-term u se, alcohol may cause liver dysfunction, resu ltin g in in creased estrogen
availab ility an d sexu al d ys u n ction in m en .
b. Ch ron ic u se o marijuana may reduce testosterone levels in m en an d pituitary gonadotro-
pin levels in wom en .
2. Amphetamines an d cocaine in crease sexu ality by stim u latin g dop am in ergic system s.
3. Heroin an d, to a lesser exten t, methadone are associated with su p p ressed libido, retarded
ejacu lation , an d ailu re to ejacu late.
B. Transmission of HIV
1. Becau se o th e likelih ood o tissu e tearin g leadin g to con tact with th e blood su p p ly, anal
intercourse is th e sexu al beh avior th at is riskiest or tran sm ittin g HIV (Table 19.6).
2. Patien ts wh o are HIV p ositive m u st p rotect th eir sexu al p artn ers rom in ection . I th ey ail
to do so (e.g., do n ot u se a con dom ) an d th e p h ysician h as kn owledge o su ch ailu re, th e
p h ysician m u st en su re th at th e th reaten ed p artn er is in orm ed (see Ch ap ter 23).
3. Pren atal treatm en t with antiretroviral agents su ch as zidovu din e (AZT), lam ivu din e (3TC),
an d / or n evirap in e (NTP) can red u ce th e risk o tran sm ission o HIV rom m oth er to etu s.
However, even i th ey are at h igh -risk, p regn an t wom en can n ot be com p elled to be tested
or treated (see Ch ap ter 23).
Review Test
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214 BRS Behavioral Science
25. Worried p aren ts tell th eir d octor th at (C) Reassu re th e p aren ts th at cross-gen der
th eir 8-year-old son on ly wan ts to p lay with beh avior su ch as th is is com m on an d will
girls, likes to d ress u p like a girl, an d in sists disap p ear in tim e.
on urin atin g sittin g down . He also says th at (D) In orm th e p aren ts th at it is likely
boys are d irty an d th at girls h ave b etter stu th at th e ch ild will h ave a h om osexu al
an d th at h e wan ts to be called by a girl’s orien tation .
n am e. Wh at is th e m ost ap p rop riate action (E) Teach th e p aren ts th at it is OK or th e
by the p h ysician at th is tim e? ch ild to h ave th ese in terests an d h elp
(A) Tell the paren ts to give the child a tim e-out th em accep t th e ch ild as h e is.
when ever they see him playin g with girls. (F) Tell th e p aren ts th at th ey sh ou ld
(B) Tell th e p aren ts to give th e ch ild on ly con sid er sex reassign m en t su rgery or
m ascu lin e toys su ch as tru cks an d action th e ch ild.
igu res to p lay with .
An swers an d Exp lan ation s
1. The answer is C. Like oth er m en with a h om osexu al sexu al orien tation , th is p h ysician is
likely to h ave a h istory o sexu al an tasies ab ou t m en (h eterosexu al m en com m on ly h ave
a h istory o sexu al an tasies ab ou t wom en ). Hom osexu ality is a n orm al varian t o sexu al
exp ression an d is b iologically b ased (an d see TBQ). Th ere is n o evid en ce th at it is asso-
ciated with a h istory in ad olescen ce o sed u ction by an older m an , m en tal illn ess, or a
p re eren ce or bein g alon e. Wh ile p eop le with gen der dysp h oria ( eelin g o bein g b orn in to
th e wron g b od y) m ay seek sex reassign m en t su rgery, in h om osexu ality, th ere is n o d esire
to ch an ge b iological sex.
2. The answer is D. Th e m ost ap p rop riate qu estion to ask th is p atien t is a straigh t orward
on e, or exam p le, “Do you p re er to h ave sex with m en , wom en , or both m en an d wom en ?”
Usin g d escrip tors su ch as h om osexu al, h eterosexu al, gay, an d straigh t is less likely to
clari y th e p atien t’s sexu al orien tation an d beh avior.
3. The answer is C. Th is p atien t, wh o h as always elt as i sh e were “a m an in th e body o a
wom an” in th e p resen ce o a typ ical em ale body, h as gen der dysp h oria. Fem ales with con -
gen ital virilizin g ad ren al h yp erp lasia h ave m ascu lin ized gen italia, an d tran svestic etish -
ists are always m ale. Peop le with an drogen in sen sitivity syn drom e are gen etic m ales with
em ale b odies (with wh ich th ey are con ten t); th ey m ore com m on ly h ave sexu al in terest in
m en . Lesb ian wom en h ave sexu al in terest in wom en bu t h ave a em ale gen der iden tity an d
n o desire to ch an ge th eir p h ysical sex. (See also an swers to Qu estion s 4 an d 5.)
4. The answer is B. Th is p atien t, wh o h as a em ale p h en otyp e d esp ite a m ale gen otyp e (e.g.,
n o Barr bodies in th e bu ccal sm ear), h as an drogen in sen sitivity syn drom e. In th is gen etic
de ect, b ody cells d o n ot resp on d to th e an d rogen b ein g p rodu ced by th e testes, resu lt-
in g in ailu re o p h ysical m ascu lin ization p ren atally. Th e m asses n oted by th e p atien t are
p robably testes, wh ich h ave descen ded in to th e labia. Peop le with an drogen in sen sitiv-
ity syn drom e are gen erally h eterosexu al with resp ect to p h en otyp ic sex (i.e., wom en with
sexu al in terest in m en ). (See also an swers to Qu estion s 3 an d 5.)
5. The answer is D. Th is p atien t, wh o m u st wear wom en’s cloth es to b ecom e sexu ally
arou sed, is sh owin g tran svestic etish ism . (See also an swers to Qu estion s 3 an d 4.)
6. The answer is C. Th e b est estim ate o th e occu rren ce o h om osexu ality in m en is 5%–10%.
7. The answer is A. Th e su b stan ce th at th is 50-year-old m an with breast en largem en t is m ost
likely to h ave u sed is alcoh ol. Lon g-term u se o alcoh ol dam ages th e liver, resu ltin g in
accu m u lation o estrogen s an d em in ization o th e b ody. Mariju an a, h eroin , am p h etam in e,
an d am yl n itrite are m u ch less likely to cau se estrogen accu m u lation .
8. The answer is D. 9. The answer is C. Wh ile th ey m ay be associated with loss o libido an d
erectile disorder, lu oxetin e an d oth er selective seroton in reu p take in h ibitors (SSRIs) are
m ore likely to cau se d elayed or ab sen t orgasm (orgasm ic disorder). Th at is wh y th e SSRIs
are u se u l in m an agin g p rem atu re ejacu lation . Pain –p en etration disorder is n ot associated
217
218 BRS Behavioral Science
sp eci ically with SSRI treatm en t. Th e n eu rotran sm itter alteration m ost likely to be asso-
ciated with d elayed or absen t orgasm is in creased seroton in resu ltin g rom treatm en t
with lu oxetin e. In creased d op am in e ten d s to in crease sexu al in terest an d p er orm an ce.
Decreased dop am in e, decreased seroton in , an d decreased n orep in ep h rin e are less likely to
b e associated with delayed orgasm th an is in creased seroton in .
10. The answer is A. Becau se tissu e tears p rovid in g access to th e blood su p p ly are m ore likely
to occu r in an al in tercou rse, th is is th e typ e o sexu al beh avior th at p oses th e m ost risk
or tran sm ittin g HIV. Wh ile it is p ossib le to tran sm it HIV by oth er sexu al beh aviors (e.g.,
ellatio [oral–p en ile con tact], cu n n ilin gu s [oral–vu lval con tact], vagin al in tercou rse, an d
kissin g), su ch tran sm ission is m u ch less likely th an with an al in tercou rse.
11. The answer is B. O th e listed agen ts, th e on e m ost likely to h ave cau sed erectile disorder
is p rop ran olol, an an tih yp erten sive m edication (β-b locker). Cocain e, am p h etam in es, an d
l -dop a ten d to in crease sexu al in terest an d p er orm an ce by elevatin g dop am in e availabil-
ity. Am yl n itrite (a vasod ilator) is u sed to en h an ce th e sen sation o orgasm .
12. The answer is B. Th is 65-year-old m arried cou p le is m ost likely to be h avin g sexu al p rob-
lem s b ecau se o vagin al d ryn ess du e to lack o estrogen a ter m en op au se. Agin g is also
ch aracterized by a lon ger re ractory p eriod an d delayed ejacu lation in m en an d decreased
in ten sity o orgasm in m en an d wom en . Alth ou gh sexu al beh avior m ay decrease with agin g
becau se o th ese p rob lem s, sexu al in terest rem ain s abou t th e sam e. Pain –p en etration dis-
order is n ot p articu larly associated with agin g.
13. The answer is E. Th is m an is d escrib in g p rem atu re ejacu lation , a com m on sexu al d ys u n c-
tion , wh ich o ten can b e e ectively m an aged with th e squ eeze tech n iqu e (n ot p sych o-
th erapy). Prem atu re ejacu lation is associated with an absen t p lateau p h ase o th e sexu al
resp on se cycle an d is n ot sp eci ically associated with dep ression .
14. The answer is C. 15. The answer is A. Un treated diabetes is m ost likely to be associated with
erectile disorder. Alth ou gh th e m edication s u sed to m an age th ese con dition s are associ-
ated with erectile d isorder, u n treated cardiac p roblem s, h yp erten sion , an d sch izop h ren ia
are n ot associated with erectile disorder. Alzh eim er’s disease is n ot associated with erectile
d isorder. In act, sexu al exp ression m ay be th e last orm o com m un ication in a coup le
wh ere on e p artn er h as Alzh eim er’s disease. Silden a il citrate (Viagra) works by in creasin g
th e con cen tration o cGMP, a vasodilator, in th e p en is, wh ich cau ses erection to p ersist.
16. The answer is C. Th is m an wh o m astu rbates by ru bbin g again st wom en in crowded bu ses
is exh ibitin g rotteu rism . Exh ibition ism in volves a sexu al p re eren ce or revealin g on e’s
gen itals to u n susp ectin g p erson s so th at th ey will be sh ocked. Fetish ism is a sexu al p re er-
en ce or in an im ate ob jects. Sexu al m asoch ism is a p re eren ce or receivin g p h ysical p ain or
h u m iliation . Voyeu rism is a p re eren ce or secretly watch in g p eop le u n dressin g or en gag-
in g in sexu al activity.
17. The answer is D. Th is p atien t’s erectile p rob lem s are m ost likely to be associated with h is
alcoh ol d rin kin g. Cigarette sm okin g is less likely th an alcoh ol to a ect sexu al u n ction .
l -Dop a an d cocain e ten d to in crease rath er th an decrease sexu al in terest an d p er orm an ce
by elevatin g d op am in e availability. Th e m an’s work sch edu le, wh ile stress u l, is less likely
th an alcoh ol to a ect h is sexu al u n ction in g.
18. The answer is G. Th e ten tin g e ect, elevation o th e u teru s in th e p elvic cavity, begin s du r-
in g th e excitem en t p h ase o th e sexu al resp on se cycle in wom en .
19. The answer is E. Th e sex lu sh irst ap p ears du rin g th e p lateau p h ase o th e sexu al resp on se
cycle in both m en an d wom en .
20. The answer is D. Resolu tion sh ows th e greatest di eren ce in len gth between m en an d
wom en . Men h ave a restin g (re ractory) p eriod a ter orgasm wh en restim u lation is n ot p os-
sib le. Wom en are less likely th an m en to h ave a re ractory p eriod.
21. The answer is C. Uterin e con traction s occu r m ain ly du rin g th e orgasm p h ase o th e sexu al
resp on se cycle.
Chapter 19 Sexuality 219
22. The answer is D. Th e m ost com m on cau se o p elvic in lam m atory disease (PID) in wom en
is in ection with ch lam yd ial; it m ay accou n t or as m an y as 50% o th e cases. Oth er sexu -
ally tran sm itted d iseases can also cau se PID, bu t are less com m on in th e p op u lation th an
ch lam ydial in ection .
23. The answer is F. Th e m ost ap p rop riate n ext step or th e p h ysician to take is to clari y wh at
th e cou p le m ean s by “sexu al relation s.” Sexu ally in exp erien ced p eop le m ay n ot kn ow th at
som e orm s o sexu al exp ression (e.g., ellatio, in tercou rse with ou t ejacu lation ) can n ot
resu lt in p regn an cy. It is in ap p rop riate to con d u ct p h ysical or lab oratory exam in ation s or
th e cau se o in ertility u n til th e p h ysician is assu red th at th e cou p le is h avin g sexu al in ter-
cou rse in volvin g vagin al p en etration with ejacu lation .
24. The answer is A. Th e n ext step or th e d octor to take is to reassu re th e p aren ts th at cu riosity
abou t sexu al b eh avior is typ ical or ch ild ren o th is age. Alth ou gh th e p aren ts sh ou ld sp eak
to th e ch ild to be su re th at sh e h as n ot been sexu ally ab u sed by an ad u lt, h er b eh avior
with th e oth er girl can b e exp lain ed as an attem p t to rep licate th e b eh avior o h er p aren ts.
Sin ce sexu al orien tation is p rim arily b iological, th ere is n o reason to believe th at observin g
sexu al beh avior or p layin g th e m ale role in a sexu al gam e will resu lt in th e ch ild’s h avin g
a lesbian sexu al orien tation . Sin ce p h ysical exam in ation is u n rem arkable, th e ch ild’s sex
h orm on e levels are likely to b e n orm al.
25. The answer is E. Th is 8-year-old boy, wh o h as adop ted th e p lay, dress, an d social p re er-
en ces typ ical o a sch ool-age girl, is sh owin g eviden ce o gen der d ysp h oria. Gen d er id en tity
is related to early exp osu re o th e brain to sex h orm on es an d is u n ch an geable. Th e m ost
e ective strategy in d ealin g with p aren ts o ch ildren with th is disorder is to teach th em th at
it is alrigh t or th e ch ild to h ave th ese in terests an d h elp th em accep t th e ch ild as h e or sh e
is. Presen tin g on ly m ascu lin e toys or p reven tin g u se o em in in e toys will n ot be e ective
in ch an gin g th is ch ild’s beh avior (see also an swer to Qu estion 3 above). Wh en th e ch ild
is an adu lt, h e can decide wh eth er or n ot to p u rsu e sex reassign m en t su rgery. Un like th is
ch ild, h om osexu al in divid u als are com ortable with th eir biological sex an d p re er to h ave
rom an tic an d sexu al relation sh ip s with p eop le o th eir own sex.
c ha pte r
20 Aggression an d Abu se
I. AGGRESSION
A. Social determinants of aggression
1. Factors associated with in creased aggression in clu de p overty, ru stration , p h ysical p ain ,
an d exp osu re to aggression in th e m ed ia (e.g., violence on television).
2. Ch ild ren at risk or sh owin g aggressive beh avior in adu lth ood h ave requ en tly m oved an d
ch an ged sch ools rep eatedly, h ave b een physically an d/ or sexually abused, mistreat animals
an d you n ger or weaker ch ildren , an d can n ot de er grati ication . Th eir p aren ts requ en tly
d isp lay crim in al b eh avior an d u se dru gs an d alcoh ol.
3. Hom icide occu rs m ore o ten in low socioeconomic populations , an d its in ciden ce is
in creasin g. At least h al o th e h om icides resu lt rom guns .
4. In A rican -Am erican an d wh ite males 15–24 years of age , h om icid e is th e leading an d
second leading cause of death, resp ectively; acciden ts are th e secon d an d irst leadin g
cau se o d eath in A rican Am erican an d wh ite m ales, resp ectively, in th is age grou p.
Occurrence
Annual occurrence At least 1 million cases are reported At least 1 million cases are reported
Most cases are not reported Most cases are not reported
Most likely abuser The closest family member (e.g., the mother) The closest family member (e.g., spouse,
daughter, son, or other relative) with
whom the person lives (and who is often
supported financially by the elder)
Characteristics of the Abused and the Abuser
Characteristics of Hyperactivity or mild physical handicap; child is Some degree of worsening cognitive
the abused perceived as slow or different impairment (e.g., Alzheimer’s disease)
Premature, low-birth-weight infant Physical dependence on others
Colicky or “fussy” infant Does not report the abuse but instead says
Physical resemblance to the abuser’s absent, that he fell and injured himself
rejecting, or abusive partner Incontinence
In one-third of cases, victims are younger than 5 y
of age; in one-fourth of cases, victims are 5–9
y of age
Characteristics of Substance-related disorder Substance-related disorder
the abuser Poverty Poverty
Social isolation Social isolation
Delays seeking treatment for the victim Delays seeking treatment for the victim
Personal history of abuse by caretaker or spouse
Signs of Abuse
Neglect Poor personal care and hygiene (e.g., diaper rash, Poor personal care and hygiene (e.g.,
dirty hair) urine odor in incontinent person), lack
of medication or health aids such as
eyeglasses, or dentures
Lack of needed nutrition Lack of needed nutrition
Bruises Particularly in the areas not likely to be injured Often on the inner (flexor) surfaces of the
during normal play, such as buttocks or lower arms from being grabbed
back, or not over bony prominences
Belt or belt-buckle marks
Fractures and Fractures at different stages of healing Fractures at different stages of healing
burns Spiral fractures caused by twisting the limbs Spiral fractures caused by twisting the
limbs
Cigarette and other burns Cigarette and other burns
Wrist or ankle rope burns caused by tying to a bed Wrist or ankle rope burns caused by tying
or chair to a bed or chair
Burns on the feet or buttocks caused by immersion
in hot water
Other signs Internal abdominal injuries (e.g., ruptured spleen) Internal abdominal injuries (e.g., ruptured
“Shaken baby” syndrome (i.e., retinal detachment spleen)
or hemorrhage and subdural hematoma caused Evidence of depleted personal finances
by shaking the infant to stop it from crying) (the elder’s money was spent by the
Injuries of the mouth caused by forced feeding abuser and other family members)
Injuries of the mouth caused by forced
feeding
2. Occurrence
a. An estim ated 500,000 Am erican ch ildren are sexu ally abu sed p er year.
b. Most sexu ally ab u sed ch ild ren are 8–13 years of age , an d 25% are you n ger th an
8 years old .
c. Ap p roxim ately 20% o wom en an d 5%–10% o m en rep ort sexu al abu se at som e tim e
du rin g th eir ch ild h ood an d ad olescen ce.
3. Characteristics of the sexual abuser
a. Seven ty to n in ety p ercen t o sexu al ab u sers are known to the child, an d 90% o th ese are
m en . Abou t 50% o th ese m en are relatives (e.g., u n cle, ath er, step ath er), an d 50% are
am ily acqu ain tan ces (e.g., m oth er’s boy rien d , n eigh b or).
Chapter 20 Aggression and Abuse 223
B. Legal considerations
1. Becau se rapists may use condoms to avoid con tractin g HIV or to avoid DNA iden ti ication ,
or b ecau se th ey m ay h ave d i icu lty with erection or ejacu lation , sem en m ay n ot be p res-
en t in th e vagin a or an u s o a rap e victim .
2. A victim is not required to prove that she resisted the rapist or h im to be con victed. A rap ist
can b e con victed even th ou gh th e victim asks h im to u se a con dom or oth er orm o sexu al
p rotection .
3. Certain in orm ation ab ou t th e victim (e.g., p reviou s sexu al activity, “sedu ctive” cloth in g
worn at th e tim e o th e attack) is gen erally n ot adm issible as eviden ce in rap e trials.
4. Husbands can be prosecuted or orcin g th eir wives to h ave in tercou rse. It is illegal to orce
an yon e to en gage in sexu al activity.
5. Even i a wom an con sen ts to go on a d ate with a m an an d con sen ts to sexu al activity n ot
in volvin g in tercou rse, a m an can b e p rosecu ted or rap e (“date rape ”).
6. Con sen sual sex m ay be con sidered rape (“statutory rape ”) i the victim is younger than 16 or
18 years old (depen din g on state law) or is older than this but is physically or mentally impaired.
Chapter 20 Aggression and Abuse 225
226
Chapter 20 Aggression and Abuse 227
11. A m oth er brin gs h er 9-year-old d au gh ter 13. Th e m ost ap p rop riate n ext step or th e
to th e p h ysician wh o h as been carin g or p h ysician to take is to
th e am ily or th e p ast 10 years. Th e m oth er (A) con tact th e state ch ild p rotective service
rep orts th at over th e p ast 2 weeks, th e agen cy
ch ild h as b een u rin atin g requ en tly an d (B) ask th e m oth er’s p erm ission to con su lt
com p lain in g o p ain on u rin ation . Sh e n otes with a ch ild p sych iatrist
th at 2 m on th s ago, th e ch ild sh owed th e (C) qu estion th e ath er abou t th e ch ild’s
sam e sym p tom s. Th e p h ysician ob serves rem ark
th at, wh ile orm erly rien d ly an d ou tgoin g, (D) qu estion th e ch ild u rth er to determ in e i
th e ch ild n ow seem s sad an d does n ot m ake sh e is tellin g th e tru th
eye con tact with h im . Th e m oth er also states (E) con tact a ch ild p sych iatrist to determ in e
th at sin ce sh e rem arried 5 m on th s ago, i th e ch ild is tellin g th e tru th
th e ch ild h as b een d oin g p oorly in sch ool. (F) con tact a p ed iatric gyn ecologist to
Th e m ost likely exp lan ation or th is clin ical determ in e i sexu al ab u se h as occu rred
p ictu re is th at th e ch ild
(A) is an gry th at h er m oth er rem arried 14. In evalu atin g th e risk o leavin g th is ch ild
(B) is com p lain in g to gain atten tion rom with h er p aren ts, wh ich o th e ollowin g is
h er m oth er m ost closely associated with an in creased
(C) is bein g sexu ally abu sed by th e m oth er’s risk th at th e ch ild will be abu sed again ?
n ew h u sban d (A) Th e ch ild h as a qu iet, p assive p erson ality.
(D) is com p lain in g to avoid sch ool (B) Th e p aren ts are in volved in m arital
(E) is com p lain in g to exp lain h er sch ool th erapy.
p roblem s (C) Th e p aren ts are in tellectu ally disabled.
(D) Th ere is a h istory o abu se in th e p aren ts’
12. A 93-year-old m ild ly dem en ted wom an , own ch ild h ood s.
wh o is occasion ally in con tin en t, lives (E) Th e ath er is em p loyed in law
with h er d au gh ter. Sh e atten d s a d ay care en orcem en t.
p rogram rom 9 a m to 1 pm . From 1 pm to 4
pm , a n eigh bor (wh o h as an alcoh olic son 15. Th e con cern ed m oth er o an 11-year-
an d an u n em p loyed son ) takes care o th e old boy brin gs h er son to th e doctor a ter
elderly wom an . Th e wom an is brou gh t d iscoverin g h im in bed with an d sexu ally
to th e em ergen cy room by h er dau gh ter on dlin g h is 4-year-old m ale cou sin . Th e
with in ju ries th at su ggest p h ysical ab u se. m oth er n otes th at at a recen t m eetin g, th e
Th e p erson m ost likely to h ave abu sed th is 11-year-old’s teach er rep orted th at, wh ile
wom an is h e h ad b een doin g well in sch ool an d with
(A) a d ay care p rogram worker rien ds, h is grades recen tly h ave been
(B) th e n eigh bor’s alcoh olic son slackin g an d h e h as stop p ed socializin g
(C) th e n eigh bor with th e oth er ch ild ren in class. Ph ysical
(D) th e elderly wom an’s dau gh ter exam in ation is u n rem arkable. Wh ich o th e
(E) th e n eigh b or’s u n em p loyed son ollowin g sh ou ld th e d octor con sid er f rst to
exp lain th e boy’s p roblem atic beh avior?
Questions 13 and 14 (A) He h as con du ct disorder.
(B) He h as been sexu ally abu sed by an adu lt.
A 4-year-old girl tells th e p h ysician th at h er (C) He is sh owin g n orm al p readolescen t
ath er, a law en orcem en t o icer, asked h er to beh avior.
tou ch h is p en is. Ph ysical exam in ation o th e (D) He h as op p osition al de ian t disorder.
ch ild is u n rem arkab le. (E) He is sh owin g th e em ergen ce o a
h om osexu al orien tation .
An swers an d Exp lan ation s
1. The answer is C. Beca u se th is p a tien t with an in tellectu al d isab ility ap p ears to h ave
b een n eglected , th e d octor m u st p rotect th e p atien t by im m ed iately n oti yin g th e state
a gen cy or a m ily p rotective services. Sh e d o es n ot h a ve to tell th e n ep h ew o r get h is
con sen t to d o th is (a n d see Qu estion 7). Con ron tin g th e n ep h ew ab ou t n eglectin g th e
p a tien t, cla ri yin g wh y th e p a tien t is b ein g n eglected , or sp eakin g to th e n ep h ew ab ou t
h ow to d ea l with b eh aviora l issu es in p a tien ts with Down’s syn d rom e will n ot p rotect th e
p a tien t a t th is tim e.
2. The answer is A. Th is 3-m on th -old ch ild wh o is di icu lt to arou se sh ows eviden ce, or
exam p le, decreased glu cose, in creased in su lin , an d decreased p lasm a C p ep tide, o h av-
in g received exogen ou s in su lin . It is likely th at th e m oth er h as given th e ch ild in su lin in
order to get atten tion rom m edical p erson n el, a kn own m an i estation o actitiou s disorder
im p osed on an oth er (see Ch ap ter 13) an d a orm o ch ild abu se. In in su lin om a, th ere wou ld
b e in creased rath er th an decreased p lasm a C p ep tide. Th ere is n o eviden ce o p an creatitis,
ad ren al tu m or, or n u trition al de icien cy in th is ch ild .
3. The answer is E. No on e h as th e righ t to orce an oth er p erson to h ave sexu al activity, an d
tearin g o th e vagin al ori ice, wh ile n ot a n orm al com p lication o in tercou rse a ter vagin al
d elivery, can occu r i in tercou rse is resu m ed too soon a ter ch ildbirth . However, becau se
th is wom an is a com p eten t adu lt, i sh e wan ts to ile ch arges again st h er h u sb an d , sh e m u st
rep ort th e abu se to th e p olice h ersel . Certain ly, n o on e deserves th at kin d o treatm en t, bu t
in order to get m ore in orm ation abou t th e p atien t’s m arital relation sh ip, th e m ost ap p ro-
p riate th in g or th e doctor to say to th e p atien t at th is tim e is “Please tell m e m ore abou t
you r relation sh ip with you r h u sb an d .”
4. The answer is A. A ter stabilizin g th e in an t, th e em ergen cy dep artm en t p h ysician sh ou ld
con tact th e state ch ild p rotective service agen cy to rep ort su sp ected ch ild abu se. Su bdu ral
h em atom a, retin al h em orrh age, an d retin al detach m en t are sign s o th e “sh aken baby”
syn d rom e, a orm o ch ild ab u se in wh ich an adu lt sh akes a ch ild to stop its cryin g. Th e
sh aken ch ild m ay h ave n o extern al in ju ries. Ch ild abu sers, su ch as th ese p aren ts, com m on ly
d elay seekin g treatm en t an d m ake u p som e exp lan ation or th e in ju ries su ch as “th e ch ild
ell.” Th e p h ysician m u st rep ort an y su sp icion o abu se to th e ap p rop riate au th ority, b u t
d oes n ot h ave to qu estion th e p aren ts or in orm th em o th is su sp icion . Sim ilarly, wh en a
p h ysician su sp ects ch ild p h ysical or sexu al abu se, h e or sh e d oes n ot n eed a p aren t’s p er-
m ission to exam in e, h osp italize, or treat th e ch ild or to con su lt with a sp ecialist.
5. The answer is E. An in tern al in ju ry, su ch as a ru p tu red sp leen , is m ost likely to be th e resu lt
o abu se in a 4-year-old ch ild. Ch in , kn ee, oreh ead, an d elbow in ju ries are m ore likely to
h ave b een obtain ed d u rin g n orm al p lay.
229
230 BRS Behavioral Science
I. MEDICAL PRACTICE
A. Seeking medical care
1. Patien ts’ b eh avior wh en ill an d th eir exp ectation s o p h ysician s are in lu en ced by th eir
culture (see Ch ap ter 18), p reviou s exp erien ces with m edical care, p h ysical an d m en tal
con d ition s, personality styles (n ot n ecessarily p erson ality disorders; see Table 14.3 an d
Table 21.1), an d coping skills .
2. On ly abou t one-third of Americans with symptoms seek medical care ; m ost p eop le con ten d
with illn esses at h om e with over-th e-cou n ter m edication s an d h om e m an agem en t.
232
Chapter 21 The Physician–Patient Relationship 233
Paranoid Blames the physician for the fact that he or she is ill
Schizoid Becomes even more withdrawn during illness
Schizotypal Bizarre behavior may mask serious illness
Histrionic May be dramatic, emotionally changeable, and approach the physician in an
inappropriate sexual fashion during illness
Narcissistic Has a perfect self-image, which is threatened by illness and may refuse needed
treatment, which can alter his or her appearance
Antisocial May self-write or alter prescriptions and lie to the physician
Borderline Idealizes the physician at first, may make gestures of or attempt self-harm when ill
Avoidant Interprets physician health suggestions as criticisms, fears rejection by the doctor, is
overly sensitive to a perceived lack of attention or caring
Obsessive–compulsive Fears loss of control and may in turn become more controlling during illness
Dependent Becomes more needy during illness and wants the physician to make all decisions
and assume all responsibility
Passive–aggressive Asks for help but then does not adhere to the physician’s advice
2. Critics o th e sick role th eory argu e th at it applies only to middle-class p atien ts with acu te
p h ysical illn ess, em p h asizes th e p ower o th e p h ysician , an d u n dervalu es th e in dividu al’s
social su p p ort n etwork in gettin g well.
E. Special situations
1. Patien ts m ay be afraid to ask questions abou t issu es th at are embarrassing (e.g., sexu al p rob-
lem s) or fear provoking (e.g., laboratory results). A physician should n ot try to guess what is
troublin g a p atien t; it is th e p h ysician’s respon sibility to ask about such issues in an op en -
en ded ash ion (see Section III.B.2.b.) an d address them truth ully an d ully with the patien t.
2. Ph ysician s h ave th e p rim ary resp on sibility or dealin g with adherence issues (see Section
II b elow), as well as with angry, seductive , or complaining behavior by th eir p atien ts
(Tab le 21.2). Re errals to oth er p h ysician s sh ou ld be reserved on ly or m edical an d p sy-
ch iatric p rob lem s ou tside o th e treatin g p h ysician’s ran ge o exp ertise.
II. ADHERENCE
A. Patient characteristics associated with adherence
1. Adh eren ce re ers to th e exten t to wh ich a p atien t ollows th e recom m en d ation s o th e
p h ysician , su ch as takin g m edication s on sch edu le, h avin g a n eeded m edical test or su rgi-
cal p rocedu re, an d ollowin g d irection s or ch an ges in li estyle, su ch as d iet or exercise.
234 BRS Behavioral Science
t a b l e 21.2 Do’s and Do Not’s for Answering USMLE Questions Involving Common Problems
in the Physician–Patient Relationship
Problem Do Do Not
Angry patient Do acknowledge the patient’s anger. Do not take the patient’s anger personally (the
patient is probably fearful about becoming
dependent as well as of being ill).
Complaining patient: Do encourage the patient to speak to the Do not intervene in the patient’s relationship with
about another doctor other physician directly if the patient another physician unless there is a medical
complains about a relationship with reason to do so.
another physician.
Complaining patient: Do speak to your own office staff if the Do not blame the patient for problems with you or
about you or your staff patient has a complaint about one your office staff.
of them.
Crying patient Do acknowledge the patient’s sadness Do not rush the patient or use patronizing statements
and quietly wait for the patient to such as “do not worry” to comfort the patient.
speak. Do not say “I understand.” The patient makes that
judgment.
Nonadherent patient: Do examine the patient’s willingness to Do not attempt to frighten the patient into adhering
needs to improve change his or her health-threatening (e.g., showing graphic photographs of untreated
health behavior behavior (e.g., smoking); if he or she illness).
is not willing, you must address that
issue first.
Nonadherent patient: Do identify the real reason (e.g., fear) for Do not refer the patient to another physician.
needs a test or the patient’s refusal to adhere to or to
treatment (e.g., consent to a needed intervention and
mammogram) address it.
Seductive patient Do call in a chaperone when you are Do not refuse to see the patient.
with the patient. Do not refer the patient to another physician.
Do gather information using direct rather Do not fail to act if the patient crosses a social
than open-ended questions. boundary.
Do set limits on the behavior that you will
tolerate.
Suicidal patient Do assess the seriousness of the threat. Do not assume that the threat is not serious.
Do suggest that the patient remain in Do not release a hospitalized patient who is a threat
the hospital voluntarily if the threat is to himself or herself (patients who are a threat
serious. to self or others can be held involuntarily [see
Chapter 23]).
2. Patien ts n eed to recogn ize th at th eir b eh avior or con d ition (e.g., ob esity) is p rob lem atic
b e ore th ey are m otivated to ch an ge or seek m ed ical care. Th e “Stages of Change” m od el
re ers to th e p oin t at wh ich th is recogn ition an d read in ess to ch an ge occu rs (Tab le 21.3).
3. Patien ts’ unconscious tran s eren ce reaction s to th eir p h ysician s, wh ich are based in ch ild-
h ood p aren t–ch ild relation sh ip s, can in crease or decrease adh eren ce (see Ch ap ter 6).
4. On ly abou t one-third of patients adhere fully to management recommendations , on e-th ird
adh ere som e o th e tim e, an d on e-th ird do n ot adh ere to su ch recom m en dation s.
Name of Stage
Stage # (Readiness for Change) Patient Quote Patient Characteristics Physician Strategies
Stage 1 Precontemplation (not “My father was also a big Fails to recognize or Elicit the patient’s feelings
ready for change) heavy guy—he was a denies that there is about the problem and
longshoreman and was a problem explain the risks of the
hardly ever sick.” unwanted behavior.
Stage 2 Contemplation (getting “Maybe his weight had Is ambivalent about Weigh the pros and cons of
ready for change) something to do with my making the change making the change and
father’s death, but I don’t identify things that may be
think so.” reducing the likelihood of
change.
Stage 3 Preparation (ready for “I need to lose weight; I will Trying small Prepare a plan of action for
change) try to cut back on my improvements the patient; identify social
eating.” support systems.
Stage 4 Action (makes “I ate my last pizza last Makes the needed Acknowledge the achievement.
change) night.” change
Stage 5 Maintenance “It’s really hard not to eat Continues the changed Develop strategies to manage
(continues change) too much when the behavior temptation and reward
family gets together but I success.
am doing it.”
Stage 6 Relapse (goes back on “I have been eating all the Feel guilt, anger, and Identify the factors that led
change) wrong foods all week. I disappointment to the relapse, and help
am so angry at myself.” the patient to “get back on
track.”
Good physician–patient Poor physician–patient Liking the physician is the most important factor in
relationship relationship adherence; it is even more important than the physician’s
technical skill.
Physicians perceived as unapproachable have low
adherence from patients.
Patient feels ill and usual Patient experiences few In asymptomatic illnesses, such as hypertension, only about
activities are disrupted by symptoms and little half of the patients initially adhere to management.
the illness disruption of usual Many asymptomatic patients who initially adhered have
activities stopped adhering within 1 y of diagnosis.
Short time spent in the Long time spent in the waiting Patients kept waiting get angry and then fail to adhere.
waiting room room
Belief that the benefits Belief that financial and time The “Health Belief Model” of health care
of care outweigh its costs of care outweigh its
financial and time costs benefits
Written diagnosis and Verbal diagnosis and Patients often forget what is said during a visit to the
instructions for instructions for physician because they are anxious.
management management Asking the patient to repeat your verbal instructions can
improve understanding and thus increase adherence.
Acute illness Chronic illness Chronically ill people see physicians more often but are
more critical of them than acutely ill people.
Recommending only one Recommending multiple To increase adherence, ask the patient which change they
behavioral change at behavioral changes at would like to start with and then ask the patient to make
a time once this change (e.g., stop smoking) this month and make
another change (e.g., start dieting) next month.
Recommending too many changes at once will reduce the
likelihood that the patient will make any changes.
Simple management Complex management Adherence is higher with medications that require once
schedule schedule daily dosing, preferably with a meal.
Patients are more likely to forget to take medications
requiring frequent or between-meal dosing.
Older physician Younger physician Usually, young physician age is only an issue for patients in
the initial stages of management.
Peer support Little peer support Membership in a group of people with a similar problem
(e.g., smoking [see Chapter 9]) can increase adherence.
To establish Support and To express the physician’s interest, “You must have really been frightened when
rapport empathy understanding, and concern for you realized you were going to fall.”
the patient
Validation To give value and credence to the “Many people would feel the same way if
patient’s feelings they had been injured as you were.”
To maximize Facilitation To encourage the patient to elaborate “Please tell me more about what happened
information on an answer; can be a verbal after your fall.”
gathering question or body language, such
as a quizzical expression
Reflection To encourage elaboration of the “You said that your pain increased after
answer by repeating part of the lifting the package?”
patient’s previous response
Silence To increase the patient’s Waiting silently for the patient to speak.
responsiveness
To clarify Confrontation To call the patient’s attention to “You say that you are not worried about
information inconsistencies in his or her tomorrow’s surgery, but you seem really
responses or body language upset to me.”
Recapitulation To sum up all of the information “Let’s go over what you told me. You fell last
obtained during the interview night and hurt your side. Your husband
to ensure that the physician called 911. The paramedics came but the
understands the information pain got worse until they gave you a shot
provided by the patient in the emergency room. Have I gotten it
right?”
Review Test
26. A leth argic, 19-m on th -old Mexican 28. A 16-year-old girl h as a ch ron ic disorder
Am erican boy with a tem p eratu re o 102°F th at occasion ally requ ires an op ioid
is brou gh t to th e em ergen cy room by h is an algesic. Sh e calls th e p h ysician wh en h er
m oth er. Th e p h ysician n ds th at th e ch ild is p rescrip tion ru n s ou t 2 d ays p rior to h er
dehyd rated . Wh en th e ch ild re u ses to d rin k n al exam s. Sh e lives 2 h ou rs away rom th e
water, th e d octor o ers th e ch ild a ru it- p h ysician . Th e p atien t h as access to a local
f avored ice p op. Wh en th e ch ild takes it, th e m edical clin ic th at ren ews th e p rescrip tion
m oth er becom es p an icky an d takes th e ice wh en n eeded , bu t sh e ch ecked with th em
p op away. Sh e states th at in h er cu ltu re, on e an d th ey stated th at th eir wait tim e or a visit
n ever gives ood to a ch ild with a ever. Wh at is 3 days. Th e p h ysician sh ou ld
is th e p h ysician’s n ext step ? (A) con tact th e p h arm acy with in stru ction s
(A) Exp lain th at th e ch ild n eeds reh ydration to re ill th e p rescrip tion
an d is m ore likely to eat an ice p op th an (B) recom m en d an over-th e-cou n ter
drin k water. m ed ication to treat th e p ain
(B) Follow th e m oth er’s wish es an d start an (C) con tact th e m edical clin ic an d requ est
IV to rep lace lu id s. th at th ey see th e p atien t im m ediately
(C) Call in a con su ltan t to con vin ce th e (D) ask a rien d wh o p ractices n ear th e
m oth er to allow th e ch ild to eat th e ice p atien t to p rescribe th e dru g
p op. (E) drive to th e p atien t’s h om e with a ready
(D) Exp lain to th e m oth er th at you are a p rescrip tion
licen sed p h ysician an d kn ow wh at is best
or th e ch ild. 29. A 39-year-old wom an goes to h er
(E) Exp lain to th e m oth er th at th e ch ild can p h ysician a ter discoverin g a breast m ass
die o d eh ydration . d u rin g sel -exam in ation . Two m on th s
(F) Elicit a su ggestion rom th e m oth er earlier, at h er yearly p h ysical, th e sam e
abou t h ow to b est get lu id s in to th e p h ysician h ad told th e p atien t th at all
ch ild th at its in with h er b elie s. n din gs were n orm al. Th e p atien t sch edu les
a m am m ogram an d, learn in g th at th e m ass
27. A 38-year-old p atien t asks h er p rim ary is su sp iciou s or b reast can cer, begin s to
care d octor, Dr. 1, or a re erral b ecau se won d er i th e d octor m issed n din g th e
sh e is m ovin g to a d i eren t city. Dr. 1 re ers lu m p 2 m on th s ago. Th is p atien t is m ost
th e p atien t to Dr. 2, an old m ed ical sch ool likely to le a m alp ractice su it again st th e
rien d , in th e n ew city. Wh en th e p atien t p h ysician i
goes to Dr. 2, h e n otices th at th e p atien t (A) th e biop sy in dicates th at sh e h as breast
seem s d ep ressed an d an xiou s, so h e re ers can cer
h er to Dr. 3, wh o is a p sych iatrist. Dr. 3 will (B) sh e b elieves th at sh e can get a sign i ican t
b e ou t o town or a wh ile so h e re ers th e in an cial settlem en t rom th e doctor’s
p atien t to Dr. 4. Dr. 4 h as n o tim e to see th e in su ran ce com p an y
p atien t so h e re ers h er to Dr. 5. Eth ically, (C) sh e h as p oor com m u n ication with th e
wh ich step in th e re erral sequ en ce was doctor
least ap p rop riate? (D) a am ily m em ber in sists th at sh e su e th e
(A) Dr. 1 to Dr. 2 doctor
(B) Dr. 2 to Dr. 3 (E) sh e learn s th at th e can cer h as
(C) Dr. 3 to Dr. 4 m etastasized
(D) Dr. 4 to Dr. 5
Chapter 21 The Physician–Patient Relationship 243
30. A 22-year-old m an with sch izop h ren ia 32. A wom an an d h er 15-year-old dau gh ter
is brou gh t to th e em ergen cy dep artm en t p resen t to a p h ysician’s o ce togeth er. Wh en
rom an in p atien t p sych iatric acility a h al th e p h ysician asks wh at b rin gs th em in , th e
h ou r a ter acciden tally cu ttin g h im sel wh ile m oth er states: “I wan t you to t m y dau gh ter
slicin g bread. Th e p atien t h as a 5-cm cu t on or a d iap h ragm .” Th e m ost ap p rop riate
h is h an d , wh ich requ ires su tu rin g. He re u ses action or th e p h ysician to take at th is tim e
treatm en t or th e cu t an d states “I kn ow I is to
h ave a th ou gh t p rob lem I take m ed ication (A) ollow th e m oth er’s wish es an d it th e girl
or, b u t I n ever kn ow wh o to tru st. I wan t to or a diap h ragm
wait u n til m y p aren ts get h ere. I kn ow m y (B) ask th e m oth er wh y sh e wan ts a
h an d can get in ected i I wait too lon g, b u t diap h ragm or h er d au gh ter
I don’t th in k a ew h ou rs are goin g to m ake (C) recom m en d th at th e girl see a sex
a big di eren ce.” Wh at is th e best cou rse o ed u cation cou n selor
action or th e doctor to take at th is tim e? (D) ask th e m oth er to leave an d sp eak to th e
(A) Do n ot treat an d determ in e i th e p aren ts girl alon e
are on th e way. (E) ask th e girl i th ere is som eth in g sh e
(B) Do n ot treat u n til a cou rt order is wan ts to say in p rivate
ob tain ed .
(C) Do n ot treat u n til obtain in g a p sych iatric
evalu ation .
(D) Treat becau se th e p atien t adm its h e h as
a p sych iatric disord er.
(E) Treat becau se th e p atien t h as been
p laced in a p sych iatric acility.
(F) Treat becau se th e p atien t sh ows sign s o
p aran oia an d is th u s in com p eten t.
1. The answer is A. Wh erever p ossib le, a p atien t’s wish es con cern in g h ealth care sh ou ld be
resp ected. Sin ce th is p atien t’s in ju ries are n ot li e-th reaten in g an d h er h u sban d is on th e
way, m ost ap p rop riately, th e am bu lan ce team sh ou ld wait or th e h u sban d. Takin g h er to
th e h osp ital again st h er will, waitin g u n til sh e loses con sciou sn ess an d th en takin g h er to
th e h osp ital, or tellin g h er th at th ey can n ot wait are n ot correct. Ad visin g th e p atien t th at
sh e can be p rosecu ted i sh e re u ses treatm en t is n ot tru th u l.
2. The answer is D. The n ext step in m an agem en t is to talk to th is teen age p atien t in private an d
say, “Tell m e what you thin k is goin g on” Because n othin g abn orm al is oun d on p hysical exam
an d the results o laboratory testin g are un rem arkable, doin g a toxicology screen or talkin g
to p aren ts is n ot app rop riate. Makin g a recom m en dation , or exam p le, chan gin g schools or
takin g an tidepressan ts be ore in din g out m ore about the problem is n ot app ropriate.
3. The answer is C. While in orm ation about an illn ess is given directly to an adult patien t,
paren ts decide i , how, an d when such in orm ation will be given to an ill child. In this situation ,
the physician should in d out what the child kn ows about her illn ess by askin g her what her
paren ts have told her. False reassuran ce is as in appropriate or children as it is or adults.
4. The answer is E. Th e m ost e ective statem en t or qu estion th e p h ysician can u se to h elp
th e p atien t stop sm okin g is, “Please tell m e h ow I can h elp you to stop sm okin g.” Tryin g to
righ ten th e p atien t in to adh eren ce (e.g., tellin g h im it will cau se lu n g can cer, sh owin g h im
p ictu res o lu n gs exp osed to cigarette sm oke, or askin g abou t relatives wh o died o lu n g
can cer) is less likely to b e e ective.
5. The answer is B. Th e p h ysician’s b est resp on se is to id en ti y th e sp eci ic p rob lem by askin g
th e p atien t wh at h e m ean s by “p rob lem s in b ed .” Th e p atien t’s p rob lem m u st b e id en ti ied
be ore testin g, treatm en t, or reassu ran ce is given .
6. The answer is B. Th e p h ysician’s b est resp on se is to ap ologize to th e p atien t an d o er
to sp eak to th e recep tion ist. Th e p h ysician is resp on sib le or d ealin g with illn ess-related
em otion al n eeds an d p roblem s o p atien ts an d sh ou ld n ot blam e th e p atien t, n o m atter
h ow u n p leasan t sh e is abou t p roblem s in teractin g with th e o ice sta . Th ere is n o reason to
re er th is p atien t or p sych iatric evalu ation .
7. The answer is D. Th e m ost e ective qu estion is th e m ost op en -en ded on e, or exam p le,
“Wh at do you th in k is th e im p act o you r drin kin g on you r am ily?” Qu estion s with im p lied
ju dgm en t su ch as “Do you kn ow m ost p atien ts wh o drin k as m u ch as you do lose th eir
am ilies?,” “Do you eel gu ilty ab ou t wh at you are doin g to you r ch ildren ?,” “Do you realize
th e d am age th at you r u se o alcoh ol is d oin g to you r m arriage?,” or “You r wi e says you r
drin kin g is ru in in g you r am ily” can cau se th e p atien t to becom e de en sive an d/ or an gry
an d, as su ch , are n ot likely to be h elp u l.
244
Chapter 21 The Physician–Patient Relationship 245
8. The answer is A. Patien ts wh o th row th in gs h ave lost th eir sel -con trol an d are th ere ore in
dan ger. Th e m ost im p ortan t th in g or th e residen t to d o in d ealin g with th is an gry p atien t
is to en su re both h er own an d h er p atien t’s sa ety. Th ere ore, sh e sh ou ld im m ediately alert
h osp ital secu rity. Ackn owledgin g th e p atien t’s an ger or askin g th e p atien t wh y h e is u p set
are step s th at can be taken a ter everyon e’s sa ety, in clu din g th at o th e p atien t, is en su red.
Dem an d in g th at an ou t-o -con trol p atien t stop sh ou tin g an d th rowin g th in gs is rarely
e ective.
9. The answer is C. Th e p h ysician’s b est resp on se is to say, “Please tell m e abou t wh at you
h ave b een exp erien cin g wh ile takin g Prozac,” an op en -en ded qu estion m ean t to en cou rage
th e p atien t to sp eak reely. It is likely th at th e p atien t is h avin g sexu al side e ects, com m on
with lu oxetin e, an d is u n com ortable abou t discu ssin g th em . It is n ot ap p rop riate to ju st
rep eat th e p ossible side e ects, reassu re th e p atien t, or h ave th e n u rse do th e p h ysician’s
work by talkin g to th e p atien t.
10. The answer is C. 11. The answer is C. Be ore exam in in g th is p atien t, th e p h ysician sh ou ld
ackn owledge h is an ger by sayin g, “You seem u p set.” Wh ile directed at th e p h ysician via
th e p arkin g p roblem , th e p atien t’s an ger is m ore likely to be related to h is an xiety abou t
h avin g a seriou s illn ess. Treatin g h im in a ch ild -like way (e.g., tellin g h im th at h e can n ot
b e exam in ed u n til h e calm s d own ) will u rth er an ger h im . Th e p h ysician is resp on sible or
d ealin g with illn ess-related em otion al n eeds an d p roblem s o p atien ts. Th ere is n o reason
to re er th is p atien t to an oth er p h ysician . Th e p erson ality typ e th at best describ es th is
p atien t is ob sessive–com p u lsive. Patien ts with obsessive–com p u lsive p erson ality typ es ear
loss o con trol an d m ay in tu rn b ecom e con trollin g (e.g., h avin g th e p h ysician wait wh ile
h e m akes a p h on e call) du rin g illn ess (Tab le 21.1).
12. The answer is B. 13. The answer is A. Th e p h ysician’s m ost ap p rop riate beh avior is to call in
a ch ap eron e wh en d ealin g with th is sed u ctive p atien t. Re u sin g to treat h er, askin g abou t
h er p erson al li e, or re errin g h er to an oth er p h ysician is n ot ap p rop riate. For sed u ctive
p atien ts, closed -en ded qu estion s th at lim it resp on siven ess are o ten m ore ap p rop riate
th an op en -en d ed qu estion s. Th e p erson ality typ e th at best describ es th is p atien t is
h istrion ic. Histrion ic p atien ts are d ram atic an d, like th is p atien t, m ay beh ave in a sexu ally
in ap p rop riate ash ion d u rin g illn ess (Table 21.1).
14. The answer is C. Th e m ost op en -en d ed o th ese qu estion s, “Tell m e abou t th e p ain ,” gives
little stru ctu re to th e p atien t an d can th ere ore elicit th e m ost in orm ation .
15. The answer is A. Th e in terview tech n iqu e kn own as acilitation is u sed by th e in terviewer
to en cou rage th e p atien t to elaborate on an an swer. Th e p h rase, “Please go on ,” is a
acilitative statem en t.
16. The answer is D. Th e p h ysician’s statem en t, “You look righ ten ed,” dem on strates th e
in terviewin g tech n iqu e o con ron tation , wh ich calls th e p atien t’s atten tion to th e
in con sisten cy in h is resp on se an d h is body lan gu age an d h elp s h im to exp ress h is ears.
17. The answer is B. Patien ts are m ost likely to adh ere to m edical advice becau se th ey like
th e p h ysician . Adh eren ce is also associated with sym p tom atic illn esses, older p h ysician s,
acu te illn esses, an d sim p le m an agem en t sch ed u les.
18. The answer is C. Th e act th at h e is exp erien cin g p ain is m ost likely to in crease th is
p atien t’s adh eren ce to th e m an agem en t p lan . Th ere is n o clear association between
adh eren ce an d race, socioecon om ic statu s, ed u cation , or gen d er.
19. The answer is D. Th e “sick role” ap p lies m ain ly to m idd le-class p atien ts with acu te p h ysical
illn esses. It in clu des th e exp ectation o care by oth ers, lack o resp on sibility or becom in g
ill, an d exem p tion rom on e’s u su al resp on sibilities. It u n dervalu es social su p p ort
n etworks.
20. The answer is D. 21. The answer is A. In order to get this patient to sm oke less, the physician
should irst determ in e how willin g he is to stop sm oking. A support group or m edication such
246 BRS Behavioral Science
as bupropion is only use ul or m otivated patients. This patient is not m otivated. In act, he
believes that sm okin g helps him avoid colds. Scaring patients about the consequences o their
behavior is n ot appropriate or e ective in gain in g adherence. The best thing or the physician
to say a ter the patien t has tried but n ot succeeded at stopping sm oking is a statem ent that
ackn owledges the di iculty o the task the patien t aces. Thus, the interview technique
o validation , or exam ple, “It can be really hard or people to stop sm oking,” is the m ost
appropriate statem en t to m ake at this tim e. Criticizing the patient’s behavior or threatening
to abandon the patient is not appropriate. A orm er sm okers’ support group can be a use ul
adjun ct to the physician’s program , but ackn owledging the di iculty o the task is m ore
im portan t at this tim e.
22. The answer is E. Th e p h ysician’s m ost ap p rop riate beh avior with th is p atien t wh o re u ses a
n eed ed test is to determ in e th e b asis o h is re u sal—p robably h is eelin gs abou t h is ath er’s
atal illn ess. Th e reason h e re u ses to h ave th e test p robably h as little to do with th e m ark
it will leave. Tellin g h im th at h e can b e cu red is p atron izin g, in ap p rop riate, an d p ossibly
u n tru e. Sp eakin g to h is wi e also is n ot ap p rop riate; p h ysician s sh ou ld deal d irectly with
p atien ts wh en ever p ossible. Tryin g to righ ten p atien ts abou t th e con sequ en ces o th eir
b eh avior is n ot ap p rop riate or e ective in gain in g adh eren ce.
23. The answer is B. Th e you n ger ch ild’s p h ysician sh ou ld sp eak to th e teen ager alon e as
soon as p ossib le to p rovid e in orm ation an d relieve h is ears. Th is teen ager is likely to be
righ ten ed abou t h is siblin g’s illn ess an d th e ch an ged beh avior o h is p aren ts. Adolescen ts
o ten “act ou t” wh en ear u l or d ep ressed (see Ch ap ter 6). It is th e p h ysician’s role to d eal
with p rob lem s in th e 6-year-old p atien t’s su p p ort system to redu ce stress an d th u s h elp in
recovery. Th ere is u su ally n o n eed to re er am ily m em bers to m en tal h ealth p ro ession als.
Waitin g u n til th e you n ger ch ild is ou t o dan ger will n eedlessly p rolon g th e older ch ild’s
p roblem an d u rth er stress th e am ily.
24. The answer is D. Be ore o erin g su ggestion s (e.g., “Th ere are a n u m ber o breast
recon stru ction p rocedu res th at can im p rove you r ap p earan ce”), th e p h ysician sh ou ld
try to ad dress a con cern th at m an y p atien ts h ave a ter u n d ergoin g d is igu rin g su rgery
su ch as th is, or exam p le, em barrassm en t abou t u n dressin g in ron t o h er h u sban d. Th e
p h ysician sh ou ld also avoid alsely reassu rin g or p atron izin g statem en ts su ch as, “You still
look good ,” “You still h ave on e breast,” or “Th e m ost im p ortan t th in g is th at we cau gh t th e
d isease in tim e.”
25. The answer is C. Th e m ost ap p rop riate statem en t or th e p h ysician to m ake at th is tim e
to th is wom an is to ackn owledge wh at sh e seem s to be eelin g by sayin g, “You seem to be
qu ite ten se,” sin ce sh e seem s m ore ten se an d an gry th an righ ten ed. Askin g h er wh y sh e
re u sed to ill ou t a p erson al data orm or in sistin g th at sh e do so is likely to m ake h er m ore
ten se an d an gry. Falsely reassu rin g statem en ts (see also Qu estion 24) su ch as “Th ere is
n oth in g to worry ab ou t” are p atron izin g as well as n on p rodu ctive.
26. The answer is F. I p ossible, a p h ysician sh ou ld try to work with in a p atien t’s cu ltu ral belie
system . Th u s, th is p h ysician’s n ext step in d ealin g with th is case in volvin g a deh ydrated
tod d ler is to ask th e m oth er to su ggest a m ean s o gettin g lu id in to th e ch ild th at its in
with h er cu ltu ral belie system . Startin g an IV is n ot n ecessary b ecau se th e ch ild seem s
ready to take th e ice p op by m ou th . Callin g in a con su ltan t, statin g th at you kn ow wh at
is best, or warn in g o th e worst p ossible ou tcom e will n ot oster adh eren ce or a good
p h ysician –p atien t relation sh ip.
27. The answer is B. Th e step in th e re erral sequ en ce, wh ich was least ap p rop riate, is wh en
Dr. 2 re erred th e p atien t to Dr. 3 becau se th e p atien t seem ed dep ressed an d an xiou s.
Doctor 2 sh ou ld h ave care u lly in vestigated th e p ossible m edical/ p h arm acologic cau ses o
th e p atien t’s beh avioral sym p tom s be ore decidin g on a cou rse o action . A p rim ary care
p h ysician is exp ected to address su ch beh avioral sym p tom s an d, becau se th e p atien t is
dep ressed, evalu ate su icide risk. Re errals can be in dicated wh en p atien ts ask or a re erral
(e.g., i th ey are m ovin g ou t o town ) or i th e p h ysician will n ot be available (e.g., h e or sh e
h as a u ll sch edu le).
Chapter 21 The Physician–Patient Relationship 247
28. The answer is C. Th e m ost ap p rop riate action or th e p h ysician to take is to con tact th e
local m edical clin ic, exp lain th e situ ation , an d ask th em to see th e p atien t im m ediately.
Wh ile it is n ot requ ired th at th e p h ysician drive to th e p atien t’s h om e, th e p atien t m u st
be evalu ated by a p h ysician b e ore an op ioid p rescrip tion is re illed. So, con tactin g th e
p h arm acy is n ot ap p rop riate. Patien ts with p ain severe en ou gh to requ ire op ioids are
u n likely to resp on d to over-th e-cou n ter p ain m edication .
29. The answer is C. Th is p atien t is m ost likely to ile a m alp ractice su it i sh e h as p oor
com m u n ication with th e doctor. Th e severity o th e illn ess, th e p ossible in an cial rewards
o a lawsu it, an d p ressu re rom am ily m em bers to su e are u n likely to lead to a lawsu it
wh en a p atien t likes th e doctor.
30. The answer is A. Do n ot treat an d determ in e i th e p aren ts are on th e way. Th is p atien t
ap p aren tly u n d erstan d s th e risk o waitin g bu t h as elected to wait or h is p aren ts. Un less
a p atien t is obviou sly in com p eten t becau se o cu rren t p sych otic or su icidal th in kin g, or in
im m in en t d an ger, a doctor sh ou ld ollow th e p atien t’s wish es. Havin g a p sych iatric illn ess,
bein g in a p sych iatric acility, or h avin g p aran oid th ou gh ts does n ot m ake th is p atien t
in com p eten t to m ake h ealth care decision s or h im sel (an d see Ch ap ter 23).
31. The answer is A. Th e p h ysician sh ou ld irst p lay with th e ch ild to bu ild rap p ort. A ter th e
ch ild is m ore com ortab le, th e d octor can ask h im d irect (n ot op en -en d ed ) qu estion s ab ou t
th e acciden t. Expressin g sym p ath y or coercin g th e ch ild to talk will be stress u l as well as
in e ective.
32. The answer is D. For issu es in volvin g sexu ality, th e p h ysician sh ou ld irst ask to sp eak to
th e teen ager alon e. Th e teen sh ou ld n ot be qu estion ed in ron t o h er m oth er abou t h er
(th e girl’s) n eed or sp eakin g p rivately with th e p h ysician . Th e p h ysician does n ot h ave
to ollow th e m other’s wish es or ask th e m oth er qu estion s. Th e dau gh ter is th e p atien t.
Re errin g th e teen is n ot ap p rop riate; th e p h ysician can deal with th is situ ation .
c ha pte r
22 Psych osom atic Medicin e
248
Chapter 22 Psychosomatic Medicine 249
t a b l e 22.1 Magnitude of Stress Associated with Selected Life Events According to the
Holmes and Rahe Social Readjustment Scale
Relative Stressfulness Life Event (Exact Point Value of Stressor)
C. Stressful life events. High levels o stress in a p atien t’s li e m ay be related to an increased like-
lihood of medical an d psychiatric illness .
1. Th e Social Readjustment Rating Scale (SRRS) by Holmes and Rahe (wh ich also in clu d es
“p ositive” even ts like h olid ays) ran ks th e e ects o li e even ts (Table 22.1). Even ts with th e
h igh est scores requ ire p eop le to m ake th e m ost social readju stm en t in th eir lives.
2. Th e n eed or social readju stm en t is directly correlated with in creased risk o m edical an d
p sych iatric illn ess; 80% o p atien ts with an SRRS score of 300 points in a given year becam e
ill du rin g th e n ext year.
Vitamin A Increased intracranial pressure leading Limit further use of supplements and
to headache, altered mental status, foods containing vitamin A
neurological deficits
Vitamin B6 (pyridoxine) Depression, peripheral neuropathy Limit further use of supplements and
foods containing vitamin B6
Vitamin B12 (cobalamin) Tingling and burning sensations in the Limit further use of supplements and
extremities foods containing vitamin B12
Vitamin D (pyridoxine) Confusion, apathy, poor appetite, thirst IV hydration and corticosteroids or
bisphosphonate to reduce serum
calcium levels
Iron (found in prenatal vitamins) Confusion, seizures, sedation, vomiting Give deferoxamine mesylate
“coffee grounds”
Lead (found in some paints) Depression, cognitive deficits, Give ethylenediaminetetraacetic acid
hyperactivity, aggression (EDTA)
Copper Inappropriate or psychotic behavior Give d -penicillamine
Zinc (found in denture creams) Nerve damage leading to feelings of Give EDTA
burning, numbness, and weakness
B. Hospitalized patients
1. Com m on p sych ological com p lain ts in h osp italized p atien ts in clu de an xiety, sleep disor-
ders, an d d isorien tation , o ten as a resu lt o delirium (see Ch ap ter 14) an d depression.
2. Patien ts wh o are at th e greatest risk or su ch p roblem s in clu de th ose u n dergoin g su rgery,
or ren al d ialysis, or th ose bein g treated in th e in ten sive care u n it (ICU) or coron ary care
u n it (CCU) (e.g., “ICU p sych osis”); in all grou p s, elderly patients are at in creased risk.
3. Patien ts u n dergoin g su rgery wh o are at greatest p sych ological an d m edical risk are th ose
wh o believe that they will not survive su rgery as well as th ose wh o do not admit that they are
worried b e ore su rgery.
4. Psych ological an d m ed ical risk can be red u ced by enhancing sensory an d social input (e.g.,
p lacin g th e p atien t’s bed n ear a win d ow, en cou ragin g th e p atien t to talk), p rovidin g in or-
m ation on wh at th e p atien t can exp ect du rin g an d a ter a p rocedu re, an d allowin g th e
p atien t to con trol th e en viron m en t (e.g., ligh tin g, p ain m edication ) as m u ch as p ossib le.
B. Managing pain
1. Pain relief in p ain cau sed by p h ysical illn ess is best ach ieved by analgesics (e.g., op ioids),
u sin g patient-controlled analgesia (PCA) or n erve-blockin g su rgical p rocedu res.
2. Antidepressants , are u se u l in th e m an agem en t o ch ron ic p ain .
a. An tidep ressan ts are m ost u se u l or p atien ts with arthritis, facial pain, an d headache .
b. Th eir an algesic e ect m ay be th e resu lt o stimulation of efferent inhibitory pain pathways .
c. Alth ou gh th ey h ave d irect an algesic e ects, an tidep ressan ts m ay also decrease p ain
in directly by improving mood symptoms .
3. Accord in g to th e gate control theory, th e p ercep tion o p ain can be blocked by electric
stim u lation o large-d iam eter a eren t n erves. Som e p atien ts are h elp ed by th is treatm en t.
4. Patien ts with p ain cau sed by p h ysical illn ess also b en e it rom behavioral, cognitive , an d
other psychological therapies (see Ch ap ter 17), by n eed in g less p ain m edication , b ecom -
in g m ore active, an d sh owin g in creased attem p ts to retu rn to a n orm al li estyle.
D. Pain in children
1. Ch ild ren eel p ain an d rem em b er p ain as m u ch as adu lts d o.
2. Becau se ch ild ren are a raid o in jection s, th e m ost u se u l ways o ad m in isterin g p ain m ed-
ication s to th em are orally (e.g., a en tan yl “lollip op”), transdermally (e.g., a skin cream to
p reven t p ain rom in jection s or sp in al tap s), or, in older ch ildren an d adolescen ts, via PCA.
252 BRS Behavioral Science
B. Contagion
1. I th ey com p ly with accep ted m eth ods o in ection con trol, HIV-positive physicians do not
risk transmitting the virus to their patients .
2. Few health care workers h ave con tracted HIV rom p atien ts. Th e m ain risk o tran sm ission
is th rou gh acciden tal con tam in ation rom n eedles an d oth er sh arp s, alth ou gh th is risk is
very low (see Table 19.6).
3. Un d er certain circu m stan ces, p h ysician s can iden ti y th eir HIV-p ositive p atien ts to th ose
th ey p u t at im m in en t risk (e.g., sexu al p artn ers) (see Ch ap ter 23).
Review Test
253
254 BRS Behavioral Science
11. A 45-year-old wom an with rh eu m atoid 12. A ter a 5-year-old ch ild takes h is m oth er’s
arthritis calls h er p h ysician on a Mon day p ren atal vitam in s, h e th rows u p m aterial
m orn in g becau se sh e can n ot tu rn on th e th at looks like co ee grou n ds an d th en loses
b ath tu b au cet b ecau se o th e p ain in h er con sciou sn ess. In th e em ergen cy room , th e
h an d s an d wrists. Sh e is tear u l an d says, “My p h ysician’s n ext step in p h arm acological
h u sban d h as alread y le t or work an d m y m an agem en t is to give th is ch ild
h an d s h u rt too m u ch to tu rn th e water on . (A) d -p en icillam in e
Now I can’t even take a b ath .” Wh ich o th e (B) eth ylen ed iam in etetraacetic acid (EDTA)
ollowin g is th e d octor’s m ost ap p rop riate (C) bisp h osp h on ate
resp on se? (D) de eroxam in e m esylate
(A) “I sym p ath ize with you . Un ortu n ately, (E) lu m azen il
it looks like you r on ly op tion is to wait
u n til you r h u sb an d com es h om e.”
(B) “Peop le with rh eu m atoid arth ritis o ten
eel th at th eir in dep en den ce h as been
lost becau se o th eir p ain . Perh ap s u sin g
a tool like a wren ch with a lon g h an d le
will h elp.”
(C) “Com e to th e o ice righ t away an d I will
give you a cortison e sh ot.”
(D) “I kn ow th is m u st b e d i icu lt or you ,
p erh ap s you can call a p lu m b er.”
(E) “Man y p eop le with rh eu m atoid arth ritis
h ave di icu lty tu rn in g au cets. Perh ap s
you wou ld b e in terested in join in g an
arth ritis su p p ort grou p.”
An swers an d Exp lan ation s
256
Chapter 22 Psychosomatic Medicine 257
8. The answer is D. Th ese sign s (b u tter ly rash , ever), sym p tom s ( atigu e, join t p ain ), an d
laboratory test resu lts (m ild an em ia an d p resen ce o ANA) su ggest th at th is p atien t h as
system ic lu p u s eryth em atosu s (SLE), a con n ective tissu e disorder. SLE is m ore com m on in
A rican -Am erican wom en o rep rod u ctive age an d is exacerb ated by exp osu re to th e su n
(su ch as th is p atien t exp erien ced on vacation ). Person ality ch an ges an d p sych otic sym p -
tom s, su ch as the n otion th at p eop le on television are re errin g to h er (an idea o re eren ce;
see Tab le 11.1), also occu r in con n ective tissu e disorders su ch as SLE. Dissociative u gu e,
gen eralized an xiety d isorder, b rie p sych otic disorder, an d som atic sym p tom disorder are
n ot diagn osed wh en a m edical illn ess exp lain s th e beh avioral an d p h ysical sym p tom s.
9. The answer is B. In creased TSH, decreased T3 an d ree T4 as well as tired n ess, coarsen in g
o th e voice, an d osteop orosis in d icate th at th is p atien t has h yp oth yroidism . Patien ts with
h yp oth yroidism n ot u n com m on ly p resen t with beh avioral sym p tom s su ch as th ose seen
in m ajor d ep ressive disord er. An xiety sym p tom s su ch as th ose seen in p an ic disorder an d
OCD are m ore closely associated with h yp erth yroid ism . Som atic sym p tom d isord er is
diagn osed wh en p h ysical in din gs do n ot ad equ ately exp lain th e p atien t’s sym p tom s. In
th is p atien t, th e p h ysical in din gs are sign i ican t.
10. The answer is A. Patien ts wh o u se a h elp er an im al sh ou ld be p erm itted to u se th e h elp
o th e an im al in as m an y situ ation s as p ossib le. Th ere ore, wh en it is tim e or th is blin d
p atien t to go in to th e exam in in g room , th e p h ysician sh ou ld allow th e p atien t to be led in to
th e exam in ation room by h er gu id e d og. Seein g-eye dogs are train ed to take th eir m asters
to m an y p laces an d are com m on ly allowed wh ere p et an im als are n ot, or exam p le, p u blic
bu ild in gs an d tran sp ortation . Th ere is n o reason to believe th at th e dog will in crease th e
risk o in ection or th e p atien t.
11. The answer is B. Th e doctor’s m ost ap p rop riate resp on se to th is p atien t with p ain cau sed
by rh eu m atoid arth ritis is to recogn ize th at sh e is u p set b ecau se h er in d ep en den ce h as
been lost. A p ractical su ggestion su ch as u sin g a lon g-h an d led tool is h elp u l. Tellin g h er to
wait u n til h er h usban d com es h om e or callin g a p lu m ber can in ten si y h er eelin gs o h elp -
lessn ess. Recom m en din g an arth ritis su p p ort grou p m ay be u se u l in th e lon g term bu t will
n ot h elp h er with th e cu rren t p roblem . A cortison e sh ot m igh t or m igh t n ot be h elp u l bu t
is again n ot ap p rop riate to deal with th e im m ediate p roblem .
12. The answer is D. Pren atal vitam in s con tain iron an d th is ch ild h as taken an iron overdose.
Th e p h ysician’s n ext step in m an agem en t o an iron overdose is to give de eroxam in e
m esylate. d -Pen icillam in e, eth ylen ed iam in etetraacetic acid (EDTA), bisp h osp h on ate, an d
lu m azen il are u sed to m an age overdoses o cop p er, lead, vitam in D, an d ben zodiazep in es,
resp ectively.
Legal an d Eth ical
c ha pte r
23 Issu es in Medicin e
I. LEGAL COMPETENCE
A. Definition
1. To be legally competent to m ake h ealth care decision s, a p atien t m u st u n derstan d th e
risks, benefits , an d likely ou tcom e o su ch decision s.
2. All adults (p erson s 18 years o age an d old er) are assu m ed to be legally com p eten t to m ake
h ealth care d ecision s or th em selves.
B. Minors
1. Minors (p erson s you n ger th an 18 years o age) u su ally are not con sidered legally com p eten t.
2. Emancipated minors are p eop le aged 14–17 years wh o are con sidered legally com p eten t
adu lts an d can give con sen t or th eir own m edical care.
3. To be con sidered an em an cip ated m in or, an in dividu al m u st m eet at least on e o th e ol-
lowin g criteria.
a. Be self-supporting.
b. Be in th e military.
c. Be married.
d. Have a child or wh om h e or sh e cares.
C. Questions of decision-making capacity and competence
1. I an adult’s com petence is in question (e.g., a person with an intellectual disability or dem en-
tia), physicians in volved in the case can evaluate an d testi y the capacity o the patient to m ake
a curren t health care decision. However, on ly a judge (with in put rom the patien t’s am ily or
physicians) can m ake the legal determination o com petence or uture health care decisions.
258
Chapter 23 Legal and Ethical Issues in Medicine 259
C. Special situations
1. Competent patients h ave th e right to refuse to consent to a n eeded test or p rocedu re or reli-
giou s or oth er reason s, even i th eir h ealth will su er or death will resu lt rom su ch re u sal.
2. Alth ou gh m edical or su rgical in terven tion m ay be n ecessary to p rotect th e h ealth or li e o
th e etu s, a competent pregnant woman has the right to refuse su ch in terven tion (e.g., cesar-
ean section ) even i th e etu s will d ie or be seriou sly in ju red with ou t th e in terven tion .
3. Wh ile all o th e m edical in din gs are gen erally p rovided to a p atien t, a p h ysician can
delay tellin g th e p atien t th e diagn osis i th e p h ysician believes th at su ch kn owledge will
adversely affect the patient’s health (e.g., a coron ary p atien t) or u n til th e p atien t in dicates
th at h e or sh e is read y to receive th e n ews.
4. Th e opinions of family members , wh ile h elp u l or in orm ation ab ou t th e p atien t’s state
o m in d, can n ot dictate wh at in orm ation th e p h ysician tells th e p atien t. At the patient’s
request, am ily m em bers m ay be p resen t wh en th e p h ysician p rovides th e diagn osis.
D. Unexpected findings
1. I an unexpected finding d u rin g su rgery n ecessitates a nonemergency p roced u re or wh ich
th e p atien t h as n ot given con sen t (e.g., biop sy o an u n su sp ected ovarian m align an cy
ou n d du rin g a tu b al ligation ), th e p atien t m u st be given th e op portu n ity to p rovide
in orm ed con sen t b e ore th e ad d ition al p rocedu re can b e p er orm ed.
2. In an emergency in wh ich it is im p ossible to obtain con sen t with ou t u rth er en dan gerin g
th e p atien t (e.g., a “h ot” ap p en dix is ou n d du rin g a tu bal ligation ), th e p rocedu re can be
don e with ou t obtain in g con sen t.
260 BRS Behavioral Science
E. Treatment of minors
1. On ly th e parent or legal guardian can give con sen t or su rgical or m edical treatm en t o a
m in or (p erson s u n d er age 18 years).
2. Paren tal con sen t is not required in th e treatm en t o m in ors in emergency situ ation s
(e.g., wh en th e p aren t or gu ardian can n ot b e located an d a delay in treatm en t can p oten -
tially h arm th e ch ild ). Paren tal con sen t also is n ot requ ired in th e treatm en t o m in ors
ages 14 to 17 years or:
a. Man agem en t o sexu ally tran sm itted diseases (STDs ).
b. Prescrip tion o contraceptives .
c. Medical care du rin g pregnancy.
d. Man agem en t issu es associated with drug or alcohol use .
3. Most states requ ire p aren tal n oti ication or con sen t wh en a m in or seeks an abortion.
4. A court order can be obtain ed rom a ju dge (with in h ou rs i n ecessary) i a m in or h as a li e-
threaten in g illn ess or acciden t an d the parent or guardian refuses to consent to an established
(but n ot an experim en tal) m edical or surgical in terven tion or religious or other reason s.
5. Becau se th e likelih ood o a p oor ou tcom e is in evitable or extrem ely h igh , noninitiation of
resuscitation after delivery is u su ally ap p rop riate or in an ts b orn before the 23rd gesta-
tional week, at birth weigh t less than 400 g, or with anencephaly, or trisomy 13 or 18.
6. Testin g or genetic disorders
a. I th e disord er h as a p ediatric on set an d p reven tive th erapy or treatm en t is available
(e.g., cystic ib rosis), gen etic testin g sh ou ld be o ered or even requ ired.
b. I th ere are no preventive therapies or treatm en ts or th e disorder an d it h as a pediatric
onset (e.g., Tay-Sach s d isease), parents should have the discretion as to wh eth er or n ot to
do gen etic testin g.
c. Becau se th e ch ild can m ake th e decision to be tested or n ot wh en h e or sh e is an adu lt,
gen etic testin g sh ou ld gen erally not be done :
(1) I th e disorder h as an adult onset an d th ere are n o p reven tative th erap ies (e.g.,
Hu n tin gton’s d isease).
(2) To determ in e wh eth er a p rep u bescen t ch ild is a carrier of a genetic disorder th at
will a ect h is or h er o sp rin g (e.g., ragile X syn drom e).
d. I gen etic testin g reveals in orm ation (e.g., issues of paternity) u n related to th e p resen ce
or ab sen ce o th e gen etic d isord er, it is n ot n ecessary or th e p h ysician to divu lge su ch
in orm ation to an yon e.
III. CONFIDENTIALITY
A. Alth ou gh p h ysician s are expected ethically to maintain patient confidentiality, th ey are n ot
requ ired to do so i :
1. Th eir p atien t is su sp ected o child or elder abuse .
2. Th eir p atien t h as a sign i ican t risk of suicide .
3. Th eir p atien t p oses a seriou s threat to another person.
4. Th eir p atien t p oses a risk to public safety (e.g., an im p aired d river).
B. In terven tion by th e p h ysician i th e patient poses a threat to an oth er p erson .
1. Th e p h ysician m u st irst ascertain th e credibility o th e th reat or d an ger.
2. I th e th reat or dan ger is credible, th e p h ysician m u st notify th e ap p rop riate law
en orcem en t o icials or social service agen cy an d warn th e in ten ded victim (th e
Taraso d ecision ).
B. Specific illnesses
1. “B A SSSMMART Clam or Chicken or you’re Gone.” In m ost states, h ep atitis B an d A,
Salm on ellosis, Sh igellosis, Syp h ilis, Measles, Mu m p s, AIDS, Ru bella, Tu bercu losis,
Ch lam yd ia, Ch icken p ox, an d Gon orrh ea are rep ortable.
2. STDs th at are rep ortable in m ost states in clu de AIDS, HIV-p ositive statu s is n ot rep ortable
in all states; gen ital h erp es is n ot rep ortable in m ost states.
3. Quarantine, th e seclu sion o in divid u als rom society du rin g the in ectiou s p eriod, is lim -
ited to illn esses su ch as cholera, diphtheria, tuberculosis, plague, small pox, viral hemorrhagic
fevers (e.g., Ebola and Marburg), and severe acute respiratory syndromes. Diseases su ch as
m easles, m u m p s, ru bella, an d ch icken p ox are n ot gen erally quaran tain able illn esses.
4. In ection with hepatitis A is related to exp osu re to infected feces as a resu lt o :
a. Poor access to clean drinking water. Hep atitis A is less com m on in th e Un ited States,
Can ada, Western Eu rop e, Au stralia, an d Jap an th an in cou n tries with p oorer p u blic
san itation su ch as Mexico an d In d ia.
b. Anal sexual contact. Hep atitis A is m ore com m on in m en wh o h ave u n p rotected an al
sex with m en .
B. HIV-positive patients
1. Eth ically an d legally, a p h ysician cannot refuse to treat HIV-p ositive p atien ts becau se o
ear o in ection .
2. A pregnant patient at h igh risk or HIV in ection cannot be tested or treated or th e viru s
(e.g., with zid ovu d in e [AZT] an d / or n evirap in e [Viram u n e]) against her will, even i th e
etu s cou ld b e ad versely a ected by su ch re u sal. A ter th e ch ild is born , however, th e
m oth er can n ot re u se to allow th e ch ild to be tested an d treated or th e viru s.
3. I a health care provider is exp osed to th e body lu ids o a p atien t wh o m ay p oten tially be
in ected with HIV (e.g., a n u rse is stu ck with a n eedle wh ile ob tain in g b lood rom a p atien t
wh ose HIV statu s is u n kn own ), it is accep table to test the patient for HIV infection even i
th e p atien t re u ses to con sen t to th e test.
4. Physician s are not required to maintain confidentiality when an HIV-p ositive patien t puts an
iden ti ied person at risk by en gagin g in un protected sex (see Section III.B above).
C. Patients , wh o are con in ed to m en tal h ealth acilities, wh eth er volu n tarily or in volu n tarily,
h ave th e right to receive treatment an d to refuse treatment (e.g., m edication , electrocon vu lsive
th erapy). Patien ts wh o are actively p sych otic or su icidal, h owever, gen erally can n ot re u se
treatm en t aim ed at stabilizin g th eir con dition .
262 BRS Behavioral Science
B. Persistent vegetative state (PVS). A p erson in a PVS m ay appear to be awake with eyes open
bu t is n ot aware o oth ers or o th e en viron m en t an d is n ot exp ected to ever recover brain
u n ction . Wh eth er to m ain tain a PVS p atien t on li e su p p ort is dep en den t u p on h is or h er
advan ce directives or on th e d ecision s o su rrogates.
C. Surrogates
1. I an in com p eten t p atien t does n ot h ave an advance directive , p eop le wh o kn ow th e
p atien t, or exam p le, am ily m em bers or rien ds (surrogates ), m u st d eterm in e what the
patient would have done if he or she were competent (th e su b stitu ted ju dgm en t stan d ard ).
Th e personal wishes of surrogates are irrelevant to th e m ed ical decision .
2. Th e priority order in wh ich am ily m em bers m ake th is determ in ation is th e (1) spouse, (2)
adult children, (3) parents, (4) siblings , an d, in ally, (5) other relatives . I th ere is a con lict
am on g am ily m em b ers at th e sam e p riority level an d discu ssion am on g am ily m em bers
does n ot settle th e issu e, th e eth ics com m ittee o th e h osp ital m ay m ake th e d ecision . For
in tractab le disagreem en t, legal in terven tion (e.g., by a ju dge) m ay be n ecessary.
3. Even i a h ealth care p roxy or su rrogate h as been m akin g decision s or an in com p eten t
p atien t, i th e p atien t regains function (com p eten ce) even brie ly or in term itten tly, he or she
regain s the right durin g those periods to m ake decision s about his or her own health care.
B. Organ donation
1. A p atien t’s organs cannot be harvested after death u n less th e p atien t (or p aren t i th e p atien t
is a m in or) h as sign ed a d ocu m en t (e.g., an organ d on or card) or in orm ed su rrogates o
h is or h er wish to d on ate.
2. A minor (bu t n ot an adu lt) can be compelled to donate tissu e (e.g., b on e m arrow, skin ) to a
close relative i h e or sh e:
a. Is th e on ly ap p rop riate sou rce.
b. Will n ot be h arm ed seriou sly by th e don ation .
C. Euthanasia. Accord in g to m edical codes o eth ics (e.g., th ose o th e Am erican Med ical
Association an d m edical sp ecialty organ ization s), euthanasia (directly killin g a p atien t or
com p assion ate reason s) is a criminal act an d is never appropriate.
1. Physician-assisted suicide (providin g a m eans or a patient to com m it suicide or com pas-
sion ate reason s) is legal in som e states but is not generally an indictable o ense in other states
as lon g as the physician does n ot actually per orm the killing (e.g., the patient injects him sel ).
2. There is no ethical distinction between withholding an d withdrawing li e-sustain in g treatm en t.
a. I requ ested by a com p eten t p atien t, ood, water, an d m edical care can be with h eld
rom a p atien t wh o h as no reasonable prospect of recovery.
b. I a com p eten t p atien t requests removal of artificial life support (e.g., ven tilator su p -
p ort), it is both legal and ethical or a p h ysician to com p ly with th is requ est. Su ch an
action by th e p h ysician is n ot con sidered eu th an asia or assisted su icide.
B. Damages. Th e p atien t m ay be award ed com p en satory d am ages on ly, or b oth com p en satory
an d p u n itive dam ages.
1. Compensatory damages are given to reimburse th e p atien t or m ed ical b ills or lost salary
an d to com p en sate th e p atien t or p ain an d su erin g.
2. Punitive damages are awarded to th e p atien t to punish the physician an d set an exam p le
or th e m ed ical com m u n ity. Pu n itive dam ages are rare an d are awarded on ly in cases o
wan ton carelessn ess or gross n egligen ce (e.g., a dru n k su rgeon cu ts a vital n erve).
3. Ph ysician s sh ou ld avoid treating family members , close friends, or employees sin ce p erson al
eelin gs can in ter ere with p ro ession al objectivity, an d am iliarity m ay lim it qu estion s or
p h ysical exam in ation s o a sen sitive n atu re.
4. Physician s sh ould avoid accepting valuable gifts (e.g., thin gs that can be sold) rom p atien ts.
X. IMPAIRED PHYSICIANS
A. Causes o im p airm en t in p h ysician s in clu de:
1. Dru g or alcoh ol u se.
2. Ph ysical or m en tal illn ess.
3. Im p airm en t in u n ction in g associated with old age.
B. Removing an im p aired colleague, m edical studen t, or residen t rom con tact with p atien ts is an
ethical requirem en t because patien ts m ust be protected an d the im paired colleague should
be helped. The legal requirem en t or reportin g im paired colleagues varies am on g states.
1. An impaired medical student sh ou ld be rep orted to th e dean o th e m edical sch ool or th e
d ean o stu d en ts.
2. An impaired resident or attending physician should be reported to the person directly in charge
o him or her (e.g., the residen cy train in g director or the chie o the m edical sta , respectively).
3. Impaired physicians in p rivate p ractice sh ou ld be rep orted to th e state licen sin g board or
th e im p aired p h ysician s p rogram , u su ally ru n by p h ysician s wh o are associated with th e
state m edical society.
Tab le 23.1 p rovid es “Do’s” an d “Do Not’s” or an swerin g qu estion s on th e USMLE
in volvin g legal an d eth ical issu es.
t a b l e 23.1 Do’s and Do Not’s for Answering USMLE Ethical and Legal Questions
Do Do Not
Do tell patients the complete truth about their illness and Do not cover up the truth about a patient’s condition or explain
prognosis in language they can understand. the diagnosis and prognosis using medical terms that the
patient does not understand.
Do tell patients the truth about your qualifications (e.g., Do not cover up the true status of medical students or residents
“I am a third-year medical student”). (e.g., “I am a member of the doctor’s team”).
Do speak to competent adult patients directly. Do not discuss issues concerning patients with their relatives
(e.g., spouse, adult children) or anyone else (e.g., insurance
companies) without the patients’ permission.
Do ask competent patients to consent to their own Do not ask a relative for consent to treat a patient unless the
treatment. relative has durable power of attorney.
Do encourage competent patients to make their own Do not make decisions about health care choices for patients; supply
health care choices (i.e., be autonomous). them with the information they need to make such decisions.
Do take care of your patient yourself. Do not refer your patient (no matter how difficult or offensive) to
another student, resident, or physician.
Do spend time with your patient. Do not delegate your responsibilities (e.g., giving lengthy medical
instructions to patients) to office staff (e.g., nurses).
Do make health care decisions based on what is best for Do not limit health care based on expense in time or money.
the health of the patient.
Do discuss all treatment options with patients, even if Do not restrict information about uncovered treatment options
their insurance companies do not cover such options. (such insurance company-generated “gag clauses” are
ethically unacceptable).
Do discuss with a pregnant patient the practical issues Do not advise a patient to have an abortion (unless she is at
of having and caring for the child. medical risk) no matter what the age of the mother (e.g.,
teenage) or the condition of the fetus (e.g., Down’s syndrome).
Do encourage a pregnant minor to make her own decision Do not accede to the demand of the pregnant woman’s parents
about whether or not to have an abortion. At the same to perform an abortion (even if the woman or her unborn child
time, encourage discussion between the woman and is intellectually disabled).
her parents about the best course of action.
Do provide medically needed analgesia to a terminally ill pat- Do not administer an analgesic overdose with the purpose of
ient even if it coincidentally may shorten the patient’s life. shortening a terminally ill patient’s life.
Review Test
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266 BRS Behavioral Science
39. A clearly com p eten t 50-year-old wom an (C) get p erm ission rom th e wom an’s am ily
wh o h as religiou s b elie s th at p reclu d e to do th e tran s u sion
blood tran s u sion is sch ed u led or m ajor (D) give th e wom an th e tran s u sion bu t n ot
su rgery. Prior to th e su rgery, sh e states th at tell h er abou t it
th e p h ysician is n ot to give h er a b lood (E) give th e wom an th e tran s u sion an d
tran s u sion , alth ou gh sh e m ay n eed it d u rin g in orm h er o it wh en sh e recovers rom
su rgery. I a tran s u sion becom es n ecessary th e an esth etic
du rin g su rgery, th e p h ysician sh ou ld
(A) rep lace lost body lu id s b u t n ot give th e
wom an th e tran s u sion
(B) get a cou rt order to do th e tran s u sion
An swers an d Exp lan ation s
1. The answer is A. Con tact th e wom an an d tell h er th e resu lts. Abortion is legal in th e Un ited
States, an d th e p atien t, wh o is th e p regn an t wom an , h as th e righ t to decide i sh e wan ts to
rem ain p regn an t. It is also u p to th e wom an to decide wh eth er or n ot to tell h er h u sban d o
h er p lan or abortion .
2. The answer is E. Measles is a rep ortab le d isease an d so th e p h ysician m u st rep ort th e case
to th e state h ealth d ep artm en t. Vaccin ation o ch ildren is recom m en ded bu t n ot legally
requ ired so rep ortin g to th e state ch ild p rotective services agen cy or law en orcem en t
au th orities is n ot ap p rop riate. Alth ou gh th e doctor sh ou ld recom m en d th at th e ch ild be
kep t away rom oth er ch ildren , m easles is n ot in clu d ed am on g th e qu aran tain able illn esses
(see Section IV.B.3).
3. The answer is B. Paren ts can n ot re u se n ecessary an d stan dard treatm en t or a m in or ch ild
(b elow age 18 years) or an y reason . Th e p atien t’s wish es are n ot relevan t sin ce sh e is a
m in or. Ad u lt p atien ts can re u se tests or treatm en t or religiou s or oth er reason . Th e doctor’s
an ticip ation o a lawsu it i th e p atien t d ies is n ot a reason or givin g a treatm en t.
4. The answer is E. Never ask th e p atien t ou t. On ce a doctor is in volved in th e m edical care o
a p atien t, even i h e or sh e was n ot d irectly resp on sible or th at care, or exam p le, a m edi-
cal stu den t, th ere exists a sp ecial relation sh ip with th e p atien t. Th u s, wh ile som e sp ecialty
b oard s m ay sp eci y a sp eci ic n u m ber o years to wait, th e best an swer is n ever start a
rom an tic relation sh ip with a p atien t.
5. The answer is A. As n oted ab ove, a p atien t (e.g., th e ath er) wh o is legally com p eten t can
re u se li esavin g treatm en t or h im sel or religiou s or oth er reason s, even i d eath will b e
th e ou tcom e. However, a p aren t (or gu ard ian ) can n ot re u se li esavin g treatm en t or th eir
ch ild or an y reason . Wh en th ere is tim e (h ere, 12 h ou rs), a cou rt ord er sh ou ld b e ob tain ed
b e ore treatm en t is started . In an em ergen cy, th e p h ysician can p roceed with ou t a cou rt
ord er.
6. The answer is D. Sin ce th ere is som e qu estion h ere abou t th e p atien t’s em otion al state,
evalu atin g h is su icid e risk be ore tellin g h im th e resu lts is th e best ch oice. On ly th e p h ysi-
cian (n ot a am ily m em ber) sh ou ld tell th e p atien t th e resu lts o a m ed ical test. I th e p h ysi-
cian believes th at th e p atien t’s h ealth will be adversely a ected by th e n ews o a m align an cy,
h e or sh e can d elay tellin g th e p atien t th e diagn osis u n til h e or sh e is ready to receive th e
b iop sy rep ort. Th e op in ion s o am ily m em bers m ay be h elp u l to in orm th e p h ysician
ab ou t th e p atien t’s state o m in d , b u t th e determ in ation o wh eth er an d wh en to in orm th e
p atien t m u st b e m ad e by th e p h ysician .
273
274 BRS Behavioral Science
7. The answer is C. On ly th e p aren t or legal gu ard ian can give con sen t or su rgical or m edi-
cal treatm en t o a m in or. In an em ergen cy su ch as th is, i th e p aren t or gu ard ian can n ot b e
located, treatm en t m ay p roceed with ou t con sen t. Th e babysittin g au n t an d gym teach er
h ave n o legal stan din g to m ake h ealth care decision s or th is ch ild. In th is case, waitin g to
act u n til th e p aren ts are reach ed cou ld b e h arm u l to th e ch ild.
8. The answer is C. Th e m ost ap p rop riate action or m edical stu den t X to take is to rep ort
m ed ical stu den t Y to th e dean o stu d en ts. Rep ortin g o an im p aired colleagu e is requ ired
eth ically b ecau se p atien ts m u st b e p rotected an d th e im p aired colleagu e sh ou ld be h elp ed .
Even i m edical stu d en t X asks Y wh y h e is d rin kin g or warn s Y abou t h is drin kin g, th ere is
n o gu aran tee th at Y will listen an d th at th e p atien ts will be p rotected. Rep ortin g Y to th e
p olice is n ot ap p rop riate.
9. The answer is D. Th e m ost ap p rop riate action or th e in tern ist to take is to con tin u e to
re er p atien ts to th e su rgeon with ou t revealin g h is HIV statu s, p rovided th at th e su rgeon
is p h ysically an d m en tally com p eten t to treat p atien ts an d th at h e com p lies with stan dard
p recau tion s or in ection con trol. Ph ysician -to-p atien t tran sm ission o HIV h as n ever been
con irm ed in th e Un ited States. Ph ysician s are n ot requ ired to in orm eith er p atien ts or th e
m ed ical estab lish m en t ab ou t a colleagu e’s HIV-p ositive statu s.
10. The answer is A. It is legal or a p h ysician to re u se to treat a p atien t or a n u m ber o rea-
son s (e.g., th e p h ysician h as n o available tim e in h is or h er p ractice). However, a ederal
ap p eals cou rt h as ru led recen tly th at it is illegal u n d er th e Am erican s with Disab ilities Act
or a h ealth care worker to re u se to treat a p atien t with HIV du e to ear o tran sm ission . It
is also u n eth ical (bu t p robably is n ot illegal) or a p h ysician to re u se to m an age p atien ts
with oth er com m u n icable diseases.
11. The answer is B. I a com p eten t p atien t requ ests cessation o arti icial li e su p p ort, it is
both legal an d eth ical or a p h ysician to com p ly with th is requ est.
12. The answer is C. In th is case, th e p h ysician sh ou ld carry ou t th e p atien t’s requ est an d n ot
p rovide li e su p p ort. Th is decision is based on th e p atien t’s p rior in stru ction s as p u t orth
in a written d ocu m en t, i.e., a livin g will. Th e wi e’s or adu lt ch ildren’s wish es are n ot rel-
evan t to th is decision . Un d er th ese circu m stan ces, th e p atien t’s wish es are clear, an d th ere
is n o n eed to app roach th e cou rt or th e eth ics com m ittee o th e h osp ital.
13. The answer is A. Th e m ost ap p rop riate action or th e p h ysician to take is to with draw li e
su p p ort. I a p atien t is legally dead (b rain dead), th e p h ysician can rem ove li e su p p ort
with ou t a cou rt order or con sen t rom am ily.
14. The answer is A. Th e lawsu it will b e su ccess u l i th e p atien t can p rove th at th e p h ysician
did n ot ollow th e u su al stan d ard s o p ro ession al care. An u n avorable ou tcom e alon e
(e.g., p aralysis o th e leg as an u n avoid ab le com p lication o th e su rgical p rocedu re) or n eg-
ative e ects on u n ction in g b ecau se o th e in ju ry do n ot con stitu te m alp ractice. Licen sed
p h ysician s are legally p erm itted to p er orm an y m edical or su rgical p rocedu re; th ey do n ot
h ave to b e boarded in a sp ecialty.
15. The answer is C. Th e b est reason th at th is p atien t can be h osp italized in volu n tarily is
i h e p oses a sign i ican t dan ger to h im sel or to oth ers. Tryin g to p u sh a p assen ger on to
th e tracks is su ch a d an ger. Sel -n eglect (e.g., p oor groom in g, m aln u trition ) or p sych otic
sym p tom s (e.g., h earin g voices or h avin g d elu sion s—see Ch ap ter 11) can also be grou n ds
or in volu n tary h osp italization wh en th ey con stitu te a sign i ican t, im m in en t dan ger to th is
p atien t’s li e or to oth ers.
16. The answer is D. Th e m ost ap p rop riate action or th e m edical stu d en t to take wh en a
p atien t asks h im to leave th e d elivery room is to ollow th e p atien t’s wish es. Th u s, th e stu -
den t sh ou ld in orm th e atten d in g p h ysician an d th en leave. Askin g th e residen t or p erm is-
sion or argu in g with th e p atien t (e.g., tellin g h er th at sh e m u st let h im stay b ecau se it is a
teach in g h osp ital or becau se sh e already agreed) is n ot ap p rop riate. Patien ts can re u se to
h ave train ees o an y kin d p resen t at an y tim e an d or an y reason .
Chapter 23 Legal and Ethical Issues in Medicine 275
17. The answer is D. Th e su rgeon sh ou ld exp lain th e risks o com p lication s rom both th e
su rgery an d an esth esia, in clu din g th e risk o d eath . Alth ou gh p atien ts sch ed u led or m ajor
su rgery are o ten worried, th ey h ave th e righ t to be in orm ed o all risks be ore givin g con -
sen t or a p rocedu re.
18. The answer is A. In th e absen ce o oth er in stru ction s (e.g., a DNR), th e p h ysician m u st
resu scitate th e p atien t. Askin g th e am ily or n u rsin g h om e sta wh at action to take is n ot
ap p rop riate.
19. The answer is D. Th e m ost ap p rop riate action or th e p h ysician to take is to n ote in th e
p atien t’s ch art that sh e h as re u sed to be tested an d con tin u e to care or h er. Alth ou gh p ro-
vidin g zid ovu d in e (AZT) an d / or n evirap in e (Viram u n e) to an HIV-p ositive wom an du rin g
p regn an cy can sign i ican tly redu ce th e dan ger o HIV tran sm ission to th e u n born ch ild
(see Tab le 19.6), a p regn an t wom an h as th e righ t to re u se m edical tests or treatm en t even
i th e etu s will die or be seriou sly in ju red as a resu lt. A ter th e ch ild is born , th e m oth er
can n ot re u se to h ave it tested or treated or HIV.
20. The answer is C. Th e p h ysician’s best resp on se is, “I can n ot be you r p rim ary p h ysician
becau se I am you r em p loyer.” Excep t in em ergen cy situ ation s, p h ysician s sh ou ld n ot m an -
age th e care o am ily m em bers, close rien ds, or em p loyees sin ce p erson al eelin gs can
in ter ere with m edical decision m akin g. Also, su ch p atien ts are likely to be u n com ortable
an swerin g qu estion s con cern in g sen sitive in orm ation , or h avin g in tim ate p h ysical exam i-
n ation s wh en n eeded. Ph ysician s sh ou ld n ot treat p atien ts with ou t keep in g ap p rop riate
records n or sh ould th ey write p rescrip tion s or in dividu als oth er th an p atien ts.
21. The answer is D. Th e m ost ap p rop riate action or th e p h ysician to take is to deliver th e
ch ild vagin ally. Com p eten t p regn an t wom en , like all com p eten t ad u lts, can re u se m ed ical
treatm en t, even i th e etu s will d ie as a resu lt. Neith er th e p atien t’s h u sban d (even i h e is
th e ath er) n or th e cou rt h as th e righ t to alter th is decision . Tryin g to righ ten th e p atien t by
tellin g h er th at sh e can be crim in ally p rosecu ted i th e ch ild dies (u n tru e) or re errin g h er
to an oth er p h ysician are n ot ap p rop riate action s (see also an swer to Qu estion 19).
22. The answer is B. Hep atitis A is related b oth to p oor water qu ality an d to oral–an al con tact.
Th u s, a Mexican m an with a h om osexu al orien tation (wh o en gages in oral–an al sex) is
m ost likely to b e in ected with th is viru s.
23. The answer is C. In th e absen ce o a written or verbal advan ce directive, th e p riority order
in which am ily m em bers m ake th is determ in ation is th e (1) sp ouse, (2) adu lt ch ildren , (3)
p aren ts, (4) siblin gs, an d (5) other relatives. Th e act th at the sp ou se has a legal guardian
in dicates th at she h as been declared in com p eten t. Th ere ore, th e son m akes th e decision .
Th e h osp ital eth ics com m ittee m ay be called in i th ere is a di eren ce between am ily
m em bers at th e sam e p riority level (n ot n ecessary in th is case).
24. The answer is B. Th is p h ysician is likely to b e im p aired an d th u s a p oten tial d an ger to
p atien ts. Th u s, th e colleagu e sh ou ld im m ediately n oti y th ose in ch arge at th e h osp ital th at
th e p h ysician is likely to be im p aired. Rep ortin g h im or sp eakin g to h im th e n ext day will
n ot p rotect p atien ts h e is likely to see th at even in g. Also, it m ay n ot be p ossible or th e col-
leagu e to p h ysically stop th e p h ysician rom seein g p atien ts.
25. The answer is E. It is n ot clear wh eth er or n ot th is p atien t with Down’s syn drom e u n der-
stan d s en ou gh ab ou t h er con d ition to give in orm ed con sen t. However, sin ce th ere is tim e
to m ake th is determ in ation , th e situ ation is n ot em ergen t. Th ere ore, th e p h ysician sh ou ld
evalu ate th e p atien t’s cap acity (with in p u t rom con su ltan ts i n ecessary).
26. The answer is E. Most ap p rop riately, th e su rgeon sh ou ld carry ou t th e op eration an d th en
sp eak to th e an esth esiologist alon e ab ou t h is in sen sitive beh avior. Th e eth ics com m ittee
does n ot h ave to be n oti ied i th e p atien t is n ot en d an gered an d i th e an esth esiologist’s
beh avior im p roves in th e u tu re. Askin g th e an esth esiologist to leave or an oth er su rgeon to
take over can p rolon g th e p rocedu re an d en dan ger th e an esth etized p atien t. It wou ld n ot
be h elp u l or p ro ession al to scold th e oth er doctor in a p u blic ven u e.
276 BRS Behavioral Science
27. The answer is E. With resp ect to th e p atern ity in din g, th e p h ysician sh ou ld n eith er write
it in th e ch art n or tell th e cou p le. Accordin g to th e Am erican Medical Association Code o
Medical Eth ics, it is n ot ap p rop riate or p h ysician s to d ivu lge in orm ation obtain ed seren -
dip itou sly in th e cou rse o gen etic testin g an d u n related to th e p u rp ose o th e testin g.
28. The answer is A. Most ap p rop riately, th is girl’s p aren ts sh ou ld be advised th at th e girl
sh ou ld n ot b e tested or th e ragile X gen e u n til sh e is rep rodu ctively m atu re an d requ ests
th e test or h ersel . Accordin g to th e Am erican Medical Association Code o Medical Eth ics,
“Gen etic testin g or carrier statu s sh ou ld be de erred u n til eith er th e ch ild reach es m atu -
rity, or th e ch ild n eeds to m ake rep rod u ctive d ecision s.”
29. The answer is B. Th e child’s p hysician sh ould o er the stan dard treatm en t on ly. Paren ts can
re use experim en tal (but n ot stan dard, accepted) treatm en t o their child or an y reason .
30. The answer is D. Th e irst-year resid en t sh ou ld ask th e atten din g su rgeon to get con sen t
rom th e p atien t h im sel . Con sen t can n ot be obtain ed u n til th e p atien t h as been in orm ed
an d u n derstan ds th e h ealth im p lication s o h er d iagn oses, h ealth risks, an d b en e its o
treatm en t, th e altern atives to treatm en t, likely ou tcom e i sh e does n ot con sen t to th e
treatm en t, an d th at sh e can with draw con sen t or treatm en t at an y tim e. It is n ot ap p rop ri-
ate or th e resid en t (or th e n u rse) to get con sen t sin ce h e can n ot p rovid e th e p atien t with
th is in orm ation at th e tim e th at con sen t is obtain ed.
31. The answer is C. Keep th e diagn osis con id en tial as th e p aren ts h ave requ ested. Th is in or-
m ation does directly th reaten th e sister-in -law so th e p h ysician is n ot com p elled to reveal
th e diagn osis.
32. The answer is E. Th e d octor’s best cou rse o action at th is tim e is to ask to sp eak to th e
broth er alon e th e n ext d ay an d d iscu ss h is con cern s. Peop le m ay be righ ten ed at irst by
th e p rosp ect o organ don ation bu t m ay com e arou n d in tim e. Th e an tian xiety agen t will
n ot in crease th e ch an ce th at h e will com p ly. Ultim ately, h owever, it m ay be n ecessary to
accep t th e broth er’s decision n ot to d on ate. Sin ce h e is an adu lt, th e b roth er can n ot b e
com p elled to d on ate by eith er h is p aren ts or th e cou rt. Pu ttin g m ore p ressu re on h im is
u n likely to ch an ge h is m in d at th is tim e.
33. The answer is B. Th e p h ysician sh ou ld irst ask th e p atien t wh at else h e was told . Th e doc-
tor can th en address all o th e p atien t’s con cern s abou t h is illn ess an d its m an agem en t.
34. The answer is B. Th e m ost ap p rop riate action or th e p h ysician to take at th is tim e is to
acilitate discu ssion between th e girl an d h er p aren ts con cern in g th eir disagreem en t.
Becau se th e p regn an cy is n ot th reaten in g h er li e or h ealth , th e p aren ts can n ot orce th e
girl to h ave an abortion . However, h elp in g th e am ily to com e to an agreem en t on th is issu e
is a better ch oice th an sim p ly re u sin g to do th e abortion or recom m en din g adop tion .
35. The answer is B. Most ap p rop riately, th e doctor sh ou ld tell th e m oth er th at h e can n ot reveal
in orm ation about his p atien t to her. It is n ot app rop riate to reveal in orm ation about an
adu lt p atien t (even a p erson with an in tellectu al disability) to an yon e without the patien t’s
con sen t. Addition ally, th e doctor sh ou ld n ot tell th e m oth er th at th e p atien t h as requ ested
su ch con iden tiality.
36. The answer is E. Discon tin uin g li e su pp ort is justi ied in this case because the physician
declared th e p atien t brain dead. A court order, ethics com m ittee decision , or relatives’ per-
m ission is n ot n ecessary in the decision to rem ove li e su pp ort when a patien t is brain dead.
37. The answer is C. I th e p atien t re u ses to tell h is girl rien d, th e p h ysician h ersel m u st n oti y
p u blic h ealth auth orities an d, i th ey do n ot act on th is in orm ation , in som e ju risdiction s,
also in orm th e en d an gered p artn er. I th e p atien t h ad agreed to tell h is girl rien d abou t
h is HIV statu s, the p h ysician sh ou ld set u p an ap p oin tm en t to see th e p atien t an d p art-
n er togeth er to en su re th at th e p atien t discloses h is HIV statu s to th e p artn er. Th e u su al
stan dards o p h ysician –p atien t con iden tiality do n ot ap p ly h ere sin ce th e p atien t’s ailu re
to u se con d om s p oses a sign i ican t th reat to h is girl rien d’s li e (Taraso decision ). Even i
th e p atien t is u sin g con dom s, th e p h ysician sh ou ld en cou rage h im to disclose h is m edical
con d ition to h is sexu al p artn er. Not all states requ ire rep ortin g o HIV-p ositive p atien ts.
Chapter 23 Legal and Ethical Issues in Medicine 277
38. The answer is D. In add ition to treatin g th e p atien t, th e p h ysician sh ou ld cou n sel h er
on sa e sexu al p ractices. Th ere is n o n eed to break p h ysician –p atien t con iden tiality by
tellin g th e sexu al p artn er, sin ce gen ital h erp es is n ot li e th reaten in g. Paren tal con sen t is
n ot requ ired or treatin g m in ors in cases o sexu ally tran sm itted disease, p regn an cy, an d
su b stan ce u se. Gen ital h erp es is n ot gen erally rep ortable to state h ealth au th orities.
39. The answer is A. Th e p h ysician can u se m ean s to rep lace lost b ody lu id s bu t sh ou ld n ot
give th e p atien t a blood tran s u sion . Legally com p eten t p atien ts m ay re u se treatm en t even
i death will result. Gettin g a cou rt order or obtain in g p erm ission rom th e wom an’s am ily
to do th e tran s usion is n ot ap p rop riate or eth ical. Failin g to tell a p atien t th e tru th (e.g.,
givin g th e wom an th e tran s u sion b u t n ot tellin g h er abou t it), or goin g again st a com p e-
ten t p atien t’s exp ressed wish es (e.g., in orm in g h er o th e tran s u sion wh en sh e recovers
rom th e an esth etic), is n ever ap p rop riate.
Health Care in th e
c ha pte r
24 Un ited States
C. Physicians
1. Cu rren tly, th ere are m ore th an 140 accredited allopathic medical schools an d 30 accredited
schools of osteopathic medicine in th e Un ited States, an n u ally gradu atin g over 18,000
m ed ical d octors (MDs ) an d 5,000 doctors o osteop ath y (DOs ).
a. Du e to th e in creasin g n eed or p h ysician s, th e n u m ber o sch ools an d th e n u m ber o
stu d en ts en rolled in th ese sch ools are in creasin g.
278
Chapter 24 Health Care in the United States 279
Community hospitals Total = 5,000 Nonfederal and short-term general and other
• Nongovernment not-for-profit 2,894 special hospitals (e.g., obstetrics and gynecology;
• Investor-owned (for-profit) 1,068 rehabilitation, orthopedic), and academic medical
• State and local government 1,037 centers or other teaching hospitals accessible to the
general public
Federal government hospitals 211 Veterans administration (VA) and military hospitals that
are federally owned and reserved for individuals who
have served (veterans) or are currently serving in
the military
Nonfederal psychiatric hospitals 444 Hospitals for chronically mentally ill patients
(often owned and operated by state
governments)
Nonfederal long-term care hospitals 117 Hospitals for chronically physically ill patients
From Health, United States 2014. United States Department of Health and Human Services, Centers for Disease Control and Prevention, National Center
for Health Statistics, Table 98.
b. Both MDs an d DOs are correctly called “p h ysician s.” Th ere are cu rren tly m ore th an
1,000,000 p h ysician s in th e Un ited States o wh ich abou t 82% are active.
c. Train in g an d practice are essen tially the sam e or DOs as or MDs; however, the philoso-
phy o osteop athic m edicin e speci ically stresses th e interrelatedness of body systems an d
th e use o musculoskeletal manipulation in the diagn osis an d treatm en t o physical illn ess.
d. Overall, p h ysician s earn an average in com e o $200,000 annually. Psych iatrists, p ediatri-
cian s, an d am ily p ractition ers typ ically earn less th an th is average igu re an d su rgeon s
typ ically earn m ore.
2. Primary care p h ysician s, in clu d in g am ily p ractition ers, in tern ists, an d p ed iatrician s, p ro-
vide in itial care to p atien ts an d accou n t or at least on e-th ird o all p h ysician s. Th is n u m -
b er is in creasin g an d soon is exp ected to m ake u p on e-h al o all p h ysician s.
3. Th e ratio of physicians to patients is h igh er in th e n orth eastern states an d in Cali orn ia
th an in th e sou th ern an d m ou n tain states.
4. Peop le in th e Un ited States average fewer yearly visits to p h ysician s th an p eop le in devel-
op ed cou n tries with system s o govern m en t- u n ded m edical care.
5. Seven ty- ive p ercen t o p eop le visit p h ysician s in a given year. In all age grou p s, th e
two most common medical conditions or wh ich treatm en t is sou gh t are upper respiratory
ailments an d injuries .
Residential-assisted living Long-term care Average costs range from about $36,000/y
facility, intermediate Room and board (residential-assisted living facility) to at least
care facility, and Assistance with self-care $75,000/y (skilled care facility), depending on
nursing home (i.e., Nursing care geographical area
skilled care) facility
Rehabilitation centers and Short-term care Goal is to help hospitalized patients reenter society
halfway houses Room and board
Visiting nurse association Nursing care, physical and Funded by Medicare
occupational therapy, and Serves as a less expensive alternative to
social work services hospitalization or nursing home placement
Care given in a patient’s own home
Hospice organization Supportive care to terminally ill Funded by Medicare
patients (i.e., those expected to Goal is to allow patients to die at home to be with
live, <6 mo) their families and preserve their dignity
Care usually given in a patient’s Pain medication is used liberally
own home
280 BRS Behavioral Science
B. Allocation of health care funds. Th e origin s o h ealth care exp en ses an d th e sou rces o p ay-
m en t or h ealth care are listed in Table 24.3.
a. BC/ BS p ays or h osp ital costs (Blu e Cross) an d p h ysician ees an d d iagn ostic tests
(Blu e Sh ield) or u p to h al o th e workin g p eop le in th e Un ited States.
b. Alm ost h al o BC/ BS su b scrib ers are en rolled in som e typ e o m an aged care p lan .
2. In dividu als can also con tract with on e o at least 1,000 oth er p rivate in su ran ce carriers,
su ch as Aetna or Prudential.
D. Managed care
1. Managed care describ es a h ealth care delivery system in wh ich all asp ects o an in di-
vidu al’s h ealth care are coordin ated or m an aged by a grou p o p roviders to en h an ce
cost-e ectiven ess.
2. Alth ou gh cost is con trolled in m an aged care, patients are restricted in th eir ch oice o a
p h ysician . Th u s, wh ile th e n u m ber o m an aged care p lan s is in creasin g, managed care is
more popular with the government th an with th e p u b lic.
3. Becau se ewer p atien t visits resu lt in lower costs, th e p h ilosop h y o m an aged care stresses
primary, secondary, an d tertiary prevention (Table 24.4) rath er th an acu te treatm en t.
4. Typ es o m an aged care p lan s in clu d in g h ealth m ain ten an ce organ ization s (HMOs ), p re-
erred p rovider organ ization s (PPOs ), an d p oin t o service (POS) p lan s are described in
Table 24.5.
Primary To reduce the incidence of a disorder by Immunization of infants to prevent infectious illnesses
reducing its associated risk factors Improved obstetrical care to avoid premature birth and
its associated problems
Secondary To reduce the prevalence of an existing Early identification and management of otitis media in
disorder by decreasing its severity children to prevent hearing loss
Mammography for the early identification and
management of breast cancer
Tertiary To reduce the prevalence of problems Physical therapy for stroke patients so that they can
caused by an existing disorder care for themselves
Occupational training for intellectually disabled
persons so that they can gain the skills needed to
join the work force
282 BRS Behavioral Science
Health Maintenance Physicians and other health care personnel are paid These plans are the most restrictive
Organization (HMO) a salary to provide medical services to a group of for the patient in terms of choice
(staff model or closed people who are enrolled voluntarily and who pay of doctor
panel) an annual premium Patient is assigned a “gatekeeper”
HMOs may operate their own hospitals and clinics (a primary care doctor from
Services include hospitalization, physician services, within the network who decides if
preventive medicine services, and often dental, and when a patient needs to see
eye, and podiatric care a specialist)
HMO (independent practice Physicians in private practice are hired by an HMO Private practice physicians receive
association [IPA] model) to provide services to HMO patients a fee, or capitation, for each HMO
About 65% of HMOs have IPA components patient they are responsible for
Preferred provider A third-party payer (e.g., a union trust fund, These plans guarantee doctors in
organization (PPO) insurance company, or corporation) contracts private practice a certain volume
with physicians in private practice and of patients
with hospitals to provide medical care to its By paying a larger share of the cost,
subscribers patients can choose a doctor
Participants choose physicians from a list of who is not in the network
member practitioners (the network) There is no “gatekeeper” physician
Physicians in the network receive capitation for
each patient
Point of service plan (POS) Variant of a PPO in which a third-party payer As with a PPO, patients can choose
contracts with physicians in private practice to a doctor who is not in the
provide medical care to its subscribers network by paying an extra fee
Physicians in the network receive capitation for As with an HMO, there is a
each patient “gatekeeper” physician
F. The Patient Protection and Affordable Care Act (ACA, colloquially Obamacare)
1. In 2010, Con gress p assed th e ACA, wh ich u ses a com bin ation o govern m en t u n din g an d
p rivate in su ran ce to p ay or h ealth care.
2. A ter th e ACA cam e in to e ect (a ter 2012), th e p ercen tage o u n in su red Am erican s
drop p ed rom 16.7% in 2013 to 11% in 2015.
Medicare
The federal government People eligible for Social Part A: Inpatient hospital care, home health care,
(through the Social Security benefits (e.g., those medically necessary nursing home care (for up to
Security system) at least 65 y of age regardless 90 days after hospitalization), hospice care
of income) Part B: Physician fees, dialysis, physical therapy,
People of any age with chronic laboratory tests, ambulance service, medical
disabilities or debilitating equipment (Part B is optional and has a 20%
illnesses co-payment and a $100 deductible)
Covers about 49 million people Part D: Is optional and covers a share of prescription
drug costs
Medicare does not cover long-term nursing home care
Medicaid (MediCal in California)
Both federal and state Indigent (very low-income) Inpatient and outpatient hospital care
governments (the people Physician services
state contribution is One-third of all funds is allocated Home health care, e.g., hospice care, laboratory tests,
determined by average for nursing home care for dialysis, ambulance service, medical equipment
per capita income of indigent elderly people Prescription drugs
the state) Covers about 70 million people Long-term nursing home care
Dental care, eyeglasses, hearing aids
No co-payment or deductible
Chapter 24 Health Care in the United States 283
t a b l e 24.7 Leading Causes of Death by Age Group (across Sex and Ethnic Group)
1. The answer is A. Hosp ital ch arges will b rin g th e su rgeon th e m ost m on ey each year. Th e
h igh est h ealth care costs in volve su ch ch arges. Doctor’s ch arges su ch as su rgical ees are
secon d in h ealth care costs an d m edication ch arges are th ird (see Table 24.3). Ou tp atien t
d iagn ostic testin g ch arges an d reh ab ilitation ch arges are lower.
2. The answer is C. Fin an cially, th e n eediest p atien ts are m ost likely to be h om eless p erson s.
Cardiac, b reast can cer, an d very you n g p atien ts are m ore likely th an th e h om eless to h ave
h ealth in su ran ce to p ay or th eir m edical costs. Peop le age 65+ typ ically h ave h ealth care
costs covered by Medicare.
3. The answer is A. Th e m ost im p ortan t recom m en d ation or th e p h ysician to m ake at
th is tim e to p reven t ractu res in th is wom an with osteop orosis is to sa e-p roo th e h om e
en viron m en t to red u ce th e likelih ood o alls (e.g., rem ove scatter ru gs, in stall sh ower grab
b ars) (see Ch ap ter 3). Calciu m su p p lem en ts, m edication s su ch as alen dron ate sodiu m
(Fosam ax), exercise, an d in creasin g d airy p rod u cts in th e diet are all im p ortan t or p rop h y-
laxis in osteop orosis; n on e will h elp p reven t ractu res in th e sh ort term . Sin ce th is p atien t
d oes well livin g on h er own , th ere is n o reason or h er to m ove to an assisted livin g acility.
4. The answer is A. Medicare p ays or h ealth care services or person s 65 years o age an d older
an d oth ers wh o are eligible to receive Social Security ben e its. These ben e its con tin ue or
th e li e o th e in dividu al. Becau se statistically h e is likely to have a sh orter li e than a White
or Latin o m an , an A rican Am erican wom an , or a Wh ite wom an , an A rican Am erican m an
is likely to u se th e least Medicare services over the course o his li etim e (see Table 3.1).
5. The answer is D. 6. The answer is A. A wom an rom a h igh socioecon om ic grou p is likely to
b e h ealth iest wh en th e residen t irst sees h er. Wom en an d p eop le rom h igh er socioeco-
n om ic grou p s are m ore likely to seek treatm en t an d th ere ore to b e less ill wh en irst seen
by a p h ysician th an m en an d p eop le rom low socioecon om ic grou p s. A m an rom a low
socioecon om ic grou p is likely to be m ost ill wh en th e residen t irst sees h im . Low-in com e
p atien ts an d m ale p atien ts are m ore likely to d elay seekin g treatm en t. Delay in seekin g
treatm en t com m on ly resu lts in m ore severe illn ess.
7. The answer is C. Th e p ercen ta ge o th e gro ss d om estic p rod u ct (GDP) sp en t on h ealth
ca re is a b o u t 14%, a p ercen ta ge th a t is la rger th a n th at o a n y oth er d evelop ed cou n try.
8. The answer is D. Th e largest p ercen tage o p erson al h ealth care exp en ses is p aid by p rivate
h ealth in su ran ce. In decreasin g order, oth er sou rces o p aym en t or h ealth care exp en ses
are Medicare, Medicaid, an d p erson al u n ds. Mu n icip al govern m en ts p ay a relatively sm all
p ercen tage o th ese exp en ses.
9. The answer is D. In th e Un ited States, m ost h ealth care exp en ditu res are or h osp ital care.
In decreasin g order, oth er sou rces o h ealth care exp en ses are p h ysician ees, m edication s,
n u rsin g h om e care, an d d en tal services (an d see Qu estion 1).
288
Chapter 24 Health Care in the United States 289
10. The answer is C. Th e m ost com m on cau se o death in in an ts u p to 1 year o age is con -
gen ital an om alies. Prem atu rity/ low birth weigh t an d su dden in an t death syn drom e (SIDS)
are th e secon d an d th ird leadin g cau ses o d eath in th is age grou p.
11. The answer is A. 12. The answer is E. Medicare Part A will cover in p atien t h osp ital costs.
Part B covers am b u lan ce services, p h ysician ees, m edical equ ip m en t (th e walker), an d
th erapy. Th e p atien t h ersel is resp on sible or lon g-term resid en tial n u rsin g h om e acility
costs sin ce n eith er Part A or Part B o Med icare n or Blu e Cross/ Blu e Sh ield will cover su ch
costs. A ter th e p atien t’s $100,000 is exh au sted (p robably with in 1.5 years at abou t $75,000
p er year), sh e will b e in digen t an d th ere ore eligible or Medicaid. Medicaid p ays or resi-
d en tial n u rsin g h om e care an d all oth er h ealth care or in digen t p eop le.
13. The answer is B. Th e lead in g cau se o death in th e Un ited States is h eart d isease, ollowed
by can cer an d ch ron ic lower resp iratory d iseases.
14. The answer is D. In wom en , as in m en , th e m ost com m on cau se o can cer death in th e
Un ited States is can cer o th e lu n g. In wom en , th is is ollowed by breast can cer an d
colorectal can cer. Th e n u m b er o wom en gettin g lu n g can cer is in creasin g with in creased
sm okin g rates in wom en .
15. The answer is B. More p atien ts in th e Un ited States receive care in n on govern m en t, n ot-
or-p ro it h osp itals th an in ed eral, state, local-govern m en t, or in vestor-own ed h osp itals.
16. The answer is C. Th is edu cation al p rogram or adu lts with m en tal illn ess is an exam p le o
tertiary p reven tion . Tertiary p reven tion is aim ed at redu cin g th e p revalen ce o p roblem s
cau sed by an existin g disord er, m en tal illn ess in th is case. Prim ary p reven tion is aim ed at
redu cin g th e occu rren ce or in ciden ce o a disorder by redu cin g its associated risk ac-
tors (e.g., im m u n ization again st m easles). Secon dary p reven tion is aim ed at redu cin g th e
p revalen ce o an existin g disord er by redu cin g its severity (e.g., early iden ti ication an d
m an agem en t o breast can cer u sin g m am m ograp h y). Man aged care is a system o h ealth
care in wh ich all asp ects o h ealth care are coordin ated by p roviders to con trol costs.
17. The answer is C. Wh ile acciden tal p oison in g, h ou se ires, an d d rown in g are cau ses o death
in ch ild ren , in ch ildren 1–4 years o age, acciden ts in th e h om e are a m ore im p ortan t cau se
o accid en tal death . In ectiou s illn ess d u e to lack o im m u n ization rarely cau ses d eath in
Am erican ch ildren (see also Qu estion 18).
18. The answer is E. While house ires, bicyclin g acciden ts, an d drown in g cause acciden tal death
in children , ailure to wear seat belts is the m ajor cause o acciden tal death in children 4–14
years o age. While it h as been associated with in creased childhood upper respiratory sym p-
tom s, secon dh an d sm oke h as n ot been sh own to sign i ican tly a ect su rvival in children .
19. The answer is D. 20. The answer is A. Patien ts h ave th e m ost ch oice in ch oosin g a p h ysician
in a tradition al ee- or-service in d em n ity p lan . In th is typ e o p lan , th ere are n o restriction s
on p rovider ch oice or re errals. Man aged care p lan s (e.g., h ealth m ain ten an ce organ iza-
tion s [HMOs], p re erred p rovid er organ ization s [PPOs], an d p oin t o service [POS] p lan s)
h ave restriction s on p h ysician ch oice. Patien ts h ave th e least ch oice in ch oosin g a p h ysi-
cian in an HMO. HMOs are th e m ost restrictive o m an aged care p lan s or th e p atien t in
term s o ch oice o p h ysician . Rath er th an ch oosin g a p h ysician rom th e n etwork as in a
PPO or POS, in an HMO, th e p atien t is assign ed a p h ysician .
c ha pte r
25 Medical Ep idem iology
290
Chapter 25 Medical Epidemiology 291
2. Prevalen ce rate is greater th an in cid en ce rate i th e disease is lon g term . For exam p le,
becau se d iab etes lasts a li etim e, its p revalen ce is m u ch h igh er th an its in ciden ce. In con -
trast, th e p revalen ce o in lu en za, an acu te illn ess, is ap p roxim ately equ al to th e in ciden ce.
3. Health in terven tion s th at p reven t d isease (i.e., primary prevention, see Ch ap ter 24)
decrease th e in cid en ce rate o an illn ess an d u ltim ately its p revalen ce rate as well.
4. Peop le with a sp eci ic illn ess can leave th e p op u lation o p revalen t cases eith er by recover-
ing or by dying.
A. Cohort studies
1. Coh ort stu dies begin with th e iden ti ication o a sp eci ic p op u lation i.e., acoh ort, th at is
ree o the illness u n d er in vestigation at th e start o th e stu dy.
2. Followin g th e assessm en t o exp osu re to a risk actor (a variable lin ked to th e cau se o an
illn ess [e.g., sm okin g]), in cid en ce rates o illn ess between exp osed an d u n exp osed m em -
b ers o th e coh ort are com p ared . An exam p le o a coh ort stu dy wou ld be on e th at ollowed
h ealth y ad u lts rom early ad u lth ood th rou gh m idd le age to com p are th e h ealth o th ose
wh o sm oke versu s th ose wh o d o n ot sm oke.
3. Coh ort stu dies can be prospective (takin g p lace in th e p resen t tim e) or historical (som e
activities h ave taken p lace in th e p ast).
4. A clinical treatment trial is a sp ecial typ e o coh ort stu dy in wh ich m em bers o a coh ort
with a sp eci ic illn ess are given on e treatm en t an d oth er m em bers o th e coh ort are given
an oth er treatm en t or a p lacebo. Th e resu lts o th e two treatm en ts are th en com p ared .
An exam p le o a clin ical treatm en t trial wou ld be on e in wh ich th e di eren ces in su rvival
rates b etween m en with p rostate can cer wh o receive a n ew dru g an d m en with p rostate
can cer wh o receive a stan d ard d ru g are com p ared.
B. Case–control studies
1. Case–con trol stu d ies b egin with th e id en ti ication o su bjects wh o h ave a sp eci ic disorder
(cases) an d su b jects wh o do n ot h ave th at disorder (con trols).
2. In orm ation on th e prior exposure o cases and controls to risk actors is th en obtain ed. An
exam p le o a case–con trol stu dy wou ld be on e in wh ich th e sm okin g h istories o wom en
with an d with ou t breast can cer are com p ared.
3. Becau se cases are iden ti ied at th e start o th e stu dy, case–con trol stu dies are p articu larly
u se u l wh en a disease is rare in th e p op u lation .
C. Cross-sectional studies
1. Cross-section al stu dies begin wh en in orm ation is collected rom a grou p o in dividu als
wh o p rovide a snapshot in time o d isease activity.
2. Su ch stu dies can p rovide in orm ation on th e relation sh ip between risk actors an d h ealth
statu s o a grou p o in divid u als at on e sp eci ic p oin t in tim e (e.g., a ran dom telep h on e
sam p le con du cted to d eterm in e i m ale sm okers are m ore likely to h ave an u p p er resp ira-
tory in ection th an m ale n on sm okers). Th ey can also be u sed to calcu late th e p revalen ce
o a d isease in a p op u lation .
Smokers Nonsmokers
(AD) = (45)(90)
= 13.5 = Odds ratio
(BC) = (5)(60)
An odd s ratio o 13.5 m ean s th at in th is p op u lation , a p erson with lu n g can cer was 13.5
tim es m ore likely to h ave sm oked th an a p erson with ou t lu n g can cer.
A. Bias
1. A b iased test or research stu d y is on e con stru cted so th at one outcome is more likely to
occur than another.
2. Ways th at a research stu dy or clin ical treatm en t trial can be biased can be ou n d in
Table 25.1.
Example: Six research studies were conducted on the e ectiveness o a new ( ictitious) drug, “Flashless” vs. placebo or
relieving menopausal symptoms. One hundred women aged 50–70 years were recruited or each study, and each subject
was paid $1,000. Although Flashless ultimately proved to be a use ul drug that signi icantly reduced menopausal symptoms,
because all six studies were biased in di erent ways (see table below), all ailed to show the use ulness o Flashless.
1 Selection Rather than making random assignments, the Who had more severe symptoms to start with
subjects or the investigators are permitted to chose or were chosen to take Flashless
choose whether an individual will go into the rather than placebo and so also had more
drug group or the placebo group severe symptoms at the end of the study
2 Sampling Subjects who volunteer to be in a study are Only joined the study because they needed the
not representative of the population being money and as such did not represent the
studied because factors unrelated to the typical population of women using drugs
subject of the study (e.g., money) have led such as Flashless
them to volunteer
3 Recall Knowledge of the presence of a disorder alters Seemed to have more severe menopausal
the way the subject remembers his or her symptoms because they were asked about
history their symptoms to be in the study
4 Lead-time Early detection of disease is confused with Seemed to have had menopausal symptoms
increased survival or length of time that the for a longer period of time because they
symptoms have been present were identified early to be in the study
5 Surveillance People who are aware that they are being Went to the doctor more often because
followed for the development of a disease they were in the study which increased
are more likely to seek testing for and thus to the likelihood of being diagnosed with
be identified with the disease menopausal symptoms
6 Late-look People who are most ill are not included in the Who had severe menopausal symptoms chose
sample not to participate in the study, so those who
did participate had few symptoms
294 BRS Behavioral Science
B. Reducing bias in clinical treatment trials. Blin d stu dies, p lacebo-con trolled stu dies, crossover
stu d ies, an d ran d om ized stu d ies are u sed to red u ce b ias.
1. Blind studies. Th e exp ectation s o su bjects or clin ician -evalu ators can in lu en ce th e e ec-
tiven ess o treatm en t. Blin d stu d ies attem p t to redu ce th is in lu en ce.
a. In a single-blind study, th e su bject does n ot kn ow wh at treatm en t h e or sh e is receivin g.
b. In a double-blind study, n eith er th e su b ject n or th e clin ician –evalu ator kn ows wh at
treatm en t th e su bject is receivin g.
2. Placebo responses
a. In a b lin d d ru g stu d y, a su b ject m ay receive a p lacebo (an in active su bstan ce) rath er
th an th e active dru g.
b. Peop le receivin g th e placebo are th e control group; th ose receivin g th e active drug are
th e experimental group.
c. A n u m ber o su b jects in research stu dies resp on d to th e treatm en t with p laceb os alon e
(th e p laceb o e ect—an d see Ch ap ter 4).
3. Crossover studies
a. In a crossover stu dy, su b jects are ran d om ly assign ed to on e o two grou p s. Su bjects in
grou p 1 irst receive th e dru g an d su b jects in grou p 2 irst receive th e p lacebo.
b. Later in th e crossover stu d y, th e grou p s switch —th ose in grou p 1 receive th e p lacebo
an d th ose in grou p 2 receive th e d ru g.
c. Becau se all o th e su b jects receive b oth d ru g an d p lacebo, each subject acts as his or her
own control. Havin g th ese ad d ition al d ata p oin ts can e ectively double the sample size
o p atien ts in a research stu dy.
4. Randomization. In order to en su re th at th e p rop ortion o sicker an d h ealth ier p eop le is th e
sam e in th e treatm en t an d con trol (p lacebo) grou p s, su bjects are ran dom ly assign ed to
th e grou p s. Th e n u m ber o su b jects in each grou p does n ot h ave to be equ al.
Use th is in orm a tion to ca lcu la te sen sitivity, sp eci icity, p ositive p red ictive va lu e,
an d n ega tive p red ictive va lu e o th is n ew b lood test an d th e p reva len ce o HIV in th is
p op u lation .
Patients In ected with HIV Patients Not In ected with HIV Total Patients
Positive HIV blood test 160 (TP) 80 (FP) 240 (those with a + test)
Negative HIV blood test 40 (FN) 720 (TN) 760 (those with a − test)
Total patients 200 800 1,000
0.9
A
0.8
)
y
0.7
t
vi
i
t
i
s
n
0.6 B
e
s
(
e
t
0.5
a
r
e
v
FIGURE 25.1. ROC curve. Graphic rep-
i
0.4 C
t
i
s
resentation of the relationship between
o
p
0.3 sensitivity and 1 − specificity for a
e
u
screening test. The closer the curve
r
T
to the diagonal (C), the less the dis-
0.2 Us e le s s te s t criminating ability; the closer the curve
Limite d dis crimina tion “hugs” the y axis (A), the better the dis-
0.1 Be tte r dis crimina tion criminating ability of the screening test.
(Reprinted with permission from Goroll
0 AH, Muley AG. Primary Care Medicine:
Office Evaluation and Management of
0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1
the Adult Patient. 6th ed. Philadelphia,
Fa ls e pos itive ra te (1 – s pe cificity) PA: Lippincott Williams & Wilkins; 2009.)
B. Attack rate is a typ e o in cid en ce rate u sed to d escrib e d isease ou tbreaks. It is calcu lated
by dividin g th e n u m ber o p eop le wh o becom e ill du rin g a stu dy p eriod by th e n u m -
b er o p eop le at risk du rin g th e stu dy p eriod. For example, i , a ter a p icn ic, 20 ou t o 40
p eop le wh o ate ried ch icken an d 10 ou t o 50 p eop le wh o ate ried ish becom e ill, th e
attack rate is 50% or ch icken an d 20% or ish .
Review Test
298
Chapter 25 Medical Epidemiology 299
22. A stu dy is d esign ed to com p are a n ew 25. In p eop le with n o kn own risk or
m edication or Croh n’s disease with a tu bercu losis, a p ositive reaction to th e
stan dard m edication . To do th is, each o 50 p u ri ed p rotein derivative (PPD) tu bercu lin
Croh n’s disease p atien ts is allowed to decide skin test requ ires 15 m m or m ore o h ard
wh ich o th ese two treatm en t grou p s to join . swellin g at th e site. A grou p o p h ysician s
Th e m ajor reason th at th e resu lts o th is decide th at th ey are goin g to ch an ge th e
stu dy m ay n ot be valid is b ecau se o criterion or a p ositive test in a grou p o
(A) selection bias p eop le with n o kn own risk or tu b ercu losis
(B) recall bias to a h ard swellin g o 10 m m or m ore at th e
(C) sam p lin g bias site. With resp ect to th e PPD test, th is ch an ge
(D) d i eren ces in th e sizes o th e two in th e cu to p oin t is m ost likely to
grou p s (A) in crease sen sitivity
(E) th e sm all n u m b er o p atien ts in th e (B) decrease sen sitivity
stu d y (C) decrease n egative p redictive valu e
(D) in crease p ositive p redictive valu e
23. A ter a n ew an tid ep ressan t h as b een (E) in crease sp eci icity
on th e m arket or 5 years, it is d eterm in ed
th at o 2,400 p eop le wh o h ave taken th e 26. A research study is done to determ ine i
d ru g, 360 com p lain ed o p ersisten t n au sea. intravenous (IV) ibandronate sodium (Boniva)
I a p h ysician h as two p atien ts on th is will decrease the incidence rate o hip ractures
an tidep ressan t, th e p robability th at both o in perim enopausal wom en. There are 2,600
th em will exp erien ce p ersisten t n au sea is wom en in the ibandronate sodium group, o
ap proxim ately whom 130 develop hip ractures. O the 2,600
(A) 2% wom en in the placebo group, 260 develop
(B) 9% hip ractures. Based on these data, how m any
(C) 24% wom en n eed to be treated with iban dron ate
(D) 30% sodium to preven t on e hip racture?
(E) 64% (A) 1
(B) 5
24. A b lood test reveals th at a 35-year- (C) 10
old wom an at 18 weeks o gestation h as (D) 15
in creased seru m alp h a- etop rotein (AFP). (E) 20
O th e ollowin g m easu res, wh ich h as
th e greatest in f u en ce in d eterm in in g th e 27. A n ew laboratory test to detect
p redictive valu e o th is test or n eu ral tu b e osteoporosis in wom en greater than 80 years o
d e ects in th e etu s? age has a sensitivity o 90% and a speci city o
(A) Absolu te con cen tration o AFP in th e 75%. Autopsy studies suggest that osteoporosis
m atern al seru m has a prevalence o 30% or wom en in this age
(B) Fam ily h istory o dizygotic twin group. Using this in orm ation, the likelihood
p regn an cy that a wom an with a positive test actually has
(C) Prevalen ce o n eu ral tu b e d e ects in th e osteoporosis is best estim ated as
p op u lation in qu estion (A) 12.5%
(D) Sp eci icity o th e blood test (B) 30%
(E) Sen sitivity o th e blood test (C) 60%
(D) 70%
(E) 85%
An swers an d Exp lan ation s
1. The answer is E. Th is stu d y is best d escribed as a clin ical treatm en t trial, a stu d y in wh ich a
coh ort receivin g a n ew an tih istam in e is com p ared with a coh ort receivin g a p lacebo.
2. The answer is D. Th e table sh ows th at o th e 360 ovarian can cer p atien ts wh o su rvived th e
2n d year, 135 (270 - 135 = 135) su rvived th e 4th year. Th ere ore, th e ch an ce o su rvivin g or 4
years given th at th e p atien t is alive at th e en d o th e 2n d year is 135/ 360 = 37.5%.
3. The answer is E. Prevalen ce rate o an illn ess is d ecreased eith er wh en p atien ts recover or
wh en th ey die. Becau se wh en com p ared to Wh ite p atien ts, A rican Am erican p atien ts ten d
to h ave lower in com es an d decreased access to h ealth care (see Ch ap ter 18), th ey are less
likely to receive early treatm en t or disorders su ch as can cer, an d th u s m ore likely to die.
Decreased p revalen ce in A rican Am erican wom en is th u s m ore likely to b e d u e to early
death th an to recovery rom th is typ e o can cer. Resistan ce to an illn ess or im m u n ity to an
illn ess a ects in ciden ce rate, wh ich is equ al in both grou p s o wom en in th is exam p le.
4. The answer is D. 5. The answer is C. Th e in ciden ce rate o th e disease in 2013 is 100/ 1,000,
th e n u m ber diagn osed with th e illn ess divid ed by th e n um ber o p eop le at risk or th e
illn ess. Becau se th e 200 p eop le wh o got th e disease in 2012 are n o lon ger at risk or gettin g
th e illn ess in 2013, th e d en om in ator in th e equ ation (n u m ber o p eop le at risk) is 1,000
(rath er th an 1,200). Th e p revalen ce rate o th is d isease in 2013 is 300/ 1,200. Th is igu re
rep resen ts th e p eop le wh o were diagn osed in 2013 an d still h ave th e disease (100) p lu s th e
p eop le wh o were diagn osed in 2012 an d still h ave th e disease (200) divided by th e total
p op u lation at risk (1,200).
6. The answer is C. Case–con trol stu dies b egin with th e iden ti ication o su bjects wh o h ave
a sp eci ic d isord er (cases, i.e., u lcer p atien ts) an d su bjects wh o do n ot h ave th at disorder
(con trols, i.e., th ose diagn osed with oth er d isord ers). In orm ation on th e p rior exp osu re
o cases an d con trols to risk actors is th en ob tain ed. In th is case–con trol stu dy, th e
in vestigators u sed cases (u lcer p atien ts) an d con trols (p atien ts with oth er disorders) an d
looked in to th eir h istories (h osp ital records) to determ in e th e occu rren ce o an d qu an ti y
th e level o th e risk actor (i.e., em otion al stress) in each grou p. Coh ort stu dies begin with
th e iden ti ication o sp eci ic p op u lation s (coh orts), wh o are ree o illn ess at th e start o
th e stu dy an d can b e p rosp ective (takin g p lace in th e p resen t tim e) or h istorical (som e
activities h ave taken p lace in th e p ast). Clin ical treatm en t trials are coh ort stu dies in wh ich
m em bers o a coh ort with a sp eci ic illn ess are given on e treatm en t an d oth er m em bers o
th e coh ort are given an oth er treatm en t or a p lacebo. Th e resu lts o th e two treatm en ts are
th en com p ared . Cross-section al stu dies in volve th e collection o in orm ation on a disease
an d risk actors in a p op u lation at on e p oin t in tim e.
7. The answer is E. In terrater reliability is a m easu re o h ow sim ilar test in din gs are wh en u sed
by di eren t exam in ers.
302
Chapter 25 Medical Epidemiology 303
8. The answer is A. Poin t p revalen ce is th e n u m ber o p eop le wh o h ave an illn ess at a sp eci ic
p oin t in tim e (e.g., Jan u ary 1, 2015) divided by th e total p op u lation at th at tim e. In ciden ce
rate is th e n u m b er o in d ivid u als wh o d evelop an illn ess in a given tim e p eriod (com m on ly
1 year) divided by th e total n u m b er o in d ividu als at risk or th e illn ess du rin g th at tim e
p eriod . Period p revalen ce is th e n u m ber o in dividu als wh o h ave an illn ess du rin g a
sp eci ic tim e p eriod . Relative risk com p ares th e in cid en ce rate o a disord er am on g
in dividu als exp osed to a risk actor (e.g., sm okin g) with th e in ciden ce rate o th e disorder
in u n exp osed in dividu als. Th e od d s ratio is an estim ate o th e relative risk in case–con trol
stu d ies.
9. The answer is C. In lep rosy, a lon g-lastin g, in ectiou s illn ess, th e n u m b er o p eop le in
th e p op u lation wh o h ave th e illn ess (p revalen ce) is likely to exceed th e n u m ber n ewly
develop in g th e illn ess in a given year (in ciden ce). Measles, in lu en za, ru bella, an d rabies
are sh orter-lastin g illn esses th an lep rosy.
10. The answer is B. 11. The answer is A. 12. The answer is D. 13. The answer is C. A
a lse -n ega tive resu lt o ccu rs i a test d o es n ot d etect tu b ercu losis in so m eon e wh o
tru ly is in e cted . Tru e p o sitives a re ill p eo p le wh om a test h a s co rrectly id en ti ied a s
b ein g ill. Tru e n ega tives a re well p eo p le wh o m a test h a s co rrectly id en ti ied as b ein g
we ll. Fa lse p o sitives a re we ll p eo p le wh om a test h a s in co rrectly id en ti ied a s b ein g ill.
In o rd er to id en ti y a ll tru ly in ected p eop le ( TP a n d FN), th e cu to p o in t o r th e test
sh o u ld b e set a t th e p o in t o h igh est sen sitivity, th a t is, th e p o in t a t wh ich th ere a re
th e ewest n u m b er o FN. Usin g th e d a ta p rovid ed a n d a ssu m in g th ere a re a tota l o
200 yo u n g p riso n ers, th e p o sitive p red ictive va lu e ( TP/ TP + FP) o th is test is 90/ 90 +
30 = 75%.
Disease Present Disease Absent Total
Positive p red ictive valu e: 90 TP/ (90 TP + 30 FN) = 90/ 120 = 75%.
Calcu lation s sh own b elow in d icate th at i p revalen ce o th e disease is in creased in a p op u -
lation (e.g., 200 elderly m en ), p ositive p redictive valu e in creases, bu t sen sitivity does n ot
ch an ge.
Disease Present Disease Absent Total
Low-birth-weight babies A = 20 B = 30
Normal-birth-weight babies C= 2 D = 48
Speci icity: 750 (TN)/ [750 (TN) + 200 (FP)] = 0.789 or 78.9%.
Positive predictive value: 15 (TP)/ [15 (TP) + 200 (FP)]= 0.07 or 7.0%.
Decreasin g th e lower lim it o th is re eren ce test valu e (i.e., th e cu to valu e) can be exp ected
to both d ecrease th e n u m ber o alse n egatives an d in crease th e n u m ber o alse p ositives.
Su ch alteration s will b oth in crease sen sitivity (TP/ TP + FN) an d n egative p red ictive valu e
( TN/ TN + FN) a n d d ecrea se sp eci icity ( TN/ TN + FP) an d p ositive p red ictive valu e (TP/
TP + FP) o th e test. A ch an ge in th e re eren ce in terval wou ld n ot a ect th e in ciden ce or
p revalen ce o p rostate can cer in th e p op u lation .
22. The answer is A. Th e m ajor reason th at th e resu lts o th is stu dy are n ot valid is becau se
o selection b ias (i.e., th e su b jects were ab le to ch oose wh ich grou p to go in to). I very ill
p eop le were m ore likely to ch oose th e stan dard treatm en t, p eop le in th e exp erim en tal
treatm en t grou p (wh o were h ealth ier to begin with ) wou ld h ave h ad a better ou tcom e.
In recall bias, kn owledge o th e p resen ce o a disorder alters th e way su bjects rem em ber
th eir h istories. In sam p lin g bias, su bjects are ch osen to be in a stu dy becau se o th e actors
th at m ay be u n related to th e su bject o th e stu dy bu t distin gu ish th em rom th e rest o th e
p op u lation . A stu dy can b e valid even th ou gh two grou p s m ay be o di eren t sizes or th ere
are a sm all n u m ber o p atien ts in a stu dy.
23. The answer is A. Th e p rob ab ility o b oth p atien ts (A an d B) takin g th is an tidep ressan t
exp erien cin g n au sea equ als th e p rob ab ility o A exp erien cin g n au sea (360/ 2,400 = 0.15)
tim es th e p robability o B exp erien cin g n au sea (360/ 2,400 = 0.15) = 0.15 × 0.15 = 0.0225,
th at is, abou t 2%.
24. The answer is C. Th e p revalen ce o n eu ral tu b e de ects in th e p op u lation in qu estion h as
th e greatest in lu en ce in determ in in g th e p red ictive valu e o th is test or th is p atien t sin ce
p revalen ce is d irectly related to p red ictive valu e. Th e h igh er th e p revalen ce, th e h igh er
th e p ositive p red ictive valu e (PPV) an d th e lower th e n egative p redictive valu e (NPV).
Sen sitivity an d speci icity relate to wh eth er th e test in dicates th at th ere is a n eu ral tu be
de ect in an a ected etu s (sen sitivity) or th e absen ce o a n eu ral tu be de ect in a h ealth y
etu s (sp eci icity). Wh ile AFP in th e m atern al seru m or am ily h istory o dizygotic twin
p regn an cy m ay be related to wh eth er or n ot th e etu s h as a n eu ral tu be de ect, th ey are n ot
related to th e p red ictive valu e o a screen in g test.
Chapter 25 Medical Epidemiology 305
25. The answer is A. With resp ect to th e PPD test, th is ch an ge in th e cu to p oin t is m ost likely
to in crease sen sitivity an d n egative p red ictive valu e. Th is is becau se th ere will be ewer
alse n egatives, th at is, ewer p eop le wh o are actu ally at risk or TB will be iden ti ied as n ot
at risk. Th is ch an ge in th e cu to p oin t will also decrease sp eci icity an d p ositive p redictive
valu e (see also an swer to Qu estion 20).
26. The answer is E. Twen ty wom en n eed to be treated with IV iban dron ate sodiu m to p reven t
on e h ip ractu re. Th e n u m ber n eeded to treat is calcu lated as 1/ absolu te risk redu ction .
O th e 2,600 wom en in th e p laceb o grou p, 260 develop h ip ractu res. O th e 2,600 wom en
in th e ib an dron ate sodiu m grou p, 130 d evelop h ip ractu res. Th e in ciden ce rate o h ip
ractu res in th e p lacebo grou p is th ere ore 260/ 2,600 (0.1 or 10%) an d th e in cid en ce rate
o h ip ractu res in th e iban dron ate sodiu m grou p is 130/ 2,600 (0.05 or 5%). Th ere ore,
absolu te risk red u ction (ARR) is 10% − 5% = 5%. I 5% o wom en were p reven ted rom
h avin g a h ip ractu re by th e d ru g, th e NNT is 1.0 divided by 0.05, or 20.
27. The answer is C. Assu m in g a total o 1,000 wom en over age 80 years an d a p revalen ce rate
o 30% in th is age grou p, 300 wom en h ave osteop orosis an d 700 are well. O th e 300 wh o
h ave osteop orosis, a screen in g test with a sen sitivity o 90% wou ld iden ti y 270 TP an d 30
FN. O th e 700 who are well, a screen in g test with a sp eci icity o 75% wou ld iden ti y 525
TN an d 175 FP. Usin g th ese data (see table below), th e likelih ood th at a wom an with a
p ositive test actu ally h as osteop orosis (p ositive p redictive valu e [TP/ TP + FP]) is 270/ 270 +
175 = 60%.
Disease Present Disease Absent Total
306
Chapter 26 Statistical Analyses 307
t a b l e 26.1 Calculating Standard Deviation, Standard Error of the Mean, z Score, and
Confidence Interval
Standard error of the mean (SE) Estimate of the quality of the sample S
SE =
n
z score (z) Difference between one score in the distribution and the (X − X)
population mean in units of standard deviation z=
S
Confidence interval (CI ) Specifies the high and low limits of the interval in which the Cl = X ± z (SE)
true population mean lies
–
n, number of subjects; X, observed value; X, mean.
From Fadem B. Behavioral Science in Medicine. 2nd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2012:318.
D. Normal distribution. A normal distribution , also re erred to as a gau ssian or bell-shaped distri-
bu tion , is a theoretical distribu tion o scores in wh ich the m ean , m edian , an d m ode are equal.
1. Th e h igh est p oin t in th e distribu tion o scores is th e modal peak. In a bimodal distribution,
th ere are two m odal p eaks (e.g., two d istin ct p op u lation s).
2. In a n orm al distribution , ap p roxim ately 68% o the population scores all within 1, 95% all
with in 2, an d 99.7% all with in 3 stan dard deviation s o the m ean , respectively (Figure 26.1).
E. Skewed distributions. In a skewed distribution , the m odal peak shi ts to on e side (Figure 26.2).
1. In a positively skewed distribu tion (skewed to th e righ t), th e tail is toward th e righ t an d th e
m odal p eak is toward th e le t (i.e., scores clu ster toward th e low en d).
2. In a negatively skewed distribu tion (skewed to th e le t), th e tail is toward th e le t an d th e
m odal p eak is toward th e righ t (i.e., scores clu ster toward th e h igh en d).
308 BRS Behavioral Science
y
c
n
e
u
q
e
r
F
0.15% 2.35% 13.5% 34.0% 34.0% 13.5% 2.35% 0.15%
–3 –2 –1 +1 +2 +3
68%
95%
99.7%
Are a unde r the c urve
FIGURE 26.1. The normal (gaussian) distribution. The number of standard deviations (S) (−3 to +3) from the mean is shown
on the x-axis. The percentage of the population that falls under the curve within each S is shown. (From Fadem B. High-
Yield Behavioral Science. 4th ed. Baltimore, MD: Lippincott Williams & Wilkins; 2013:126.)
n
a
i
d
Norma l
e
M
e
d
o
M
n
a
S kewe d to the right
(+ s kewe d)
i
e
d
d
o
e
M
M
S kewe d to the le ft
(– s kewe d)
Bimoda l
Me a n
FIGURE 26.2. Frequency distributions. (From Fadem B. High-Yield Behavioral Science. 4th ed. Baltimore, MD: Lippincott
Williams & Wilkins; 2013:126.)
Chapter 26 Statistical Analyses 309
B. Th e null hypothesis, wh ich p ostu lates th at n o d i eren ce exists b etween grou p s, can
eith er be rejected or n ot rejected ollowin g statistical an alysis.
E ample of the null hypothesis:
1. A grou p o 20 p atien ts wh o h ave sim ilar systolic blood p ressu res at th e begin n in g o a
stu d y (tim e 1) is d ivid ed in to two grou p s o 10 p atien ts each . On e grou p is given daily
doses o an exp erim en tal dru g m ean t to lower b lood p ressu re (exp erim en tal grou p ); th e
oth er grou p is given d aily doses o a p lacebo (p lacebo grou p ). Blood p ressu re in all 20
p atien ts is m easu red 2 weeks later (tim e 2).
2. Th e n u ll h yp oth esis assu m es th at th ere are n o sign i ican t di eren ces in blood p ressu re
between th e two grou p s at tim e 2.
3. I , at tim e 2, p atien ts in th e exp erim en tal grou p sh ow systolic blood p ressu res sim ilar
to th ose in th e p lacebo grou p, the null hypothesis (i.e., th ere is n o sign i ican t di eren ce
b etween th e grou p s) is not rejected.
4. I , at tim e 2, p atien ts in th e exp erim en tal grou p h ave sign i ican tly lower or h igh er blood
p ressu res th an th ose in th e p lacebo grou p, the null hypothesis is rejected.
D. Statistical probability
1. α is a p reset level o significance , u su ally set at 0.05 by con ven tion .
2. Th e P (probability) value is th e ch an ce o a typ e I error occu rrin g.
3. I a P valu e is equ al to or less th an 0.05, th e p reset α level, it is u n likely th at a typ e I error
h as been m ade (i.e., a typ e I error is m ade 5 or ewer tim es ou t o 100 attem p ts).
4. Th ere ore, a P valu e equ al to or less th an 0.05 is gen erally con sidered to be statistically
significant.
F. Testing hypotheses involving relative risk (RR) or odds ratio (OR) (and see Chapter 25,
Section III).
1. To test th e sign i ican ce o an association between a risk actor an d a disease, con iden ce
in terval estim ates o RR or OR can b e u sed.
2. Wh en RR = 1, or OR = 1, th ere is no association b etween th e risk actor an d th e disease.
3. I 1 is in th e con iden ce in terval, th e n u ll h yp oth esis is n ot rejected; i 1 is n ot in th e con i-
d en ce in terval, th e n u ll h yp oth esis is rejected.
310 BRS Behavioral Science
E ample 26.1. In a coh ort stu d y, th e relative risk (RR) or sm okin g in relation to ch ron ic obstru c-
tive p u lm on ary disease (COPD) is d eterm in ed by level o daily sm okin g (m easu red in p acks p er
day PPD]). Th e f n d in gs (see tab le b elow) su ggest th at p eop le wh o sm oke 1 PPD or m ore h ave
a sign if can tly in creased risk or COPD b u t th at risk or COPD is n ot sign if can tly elevated or
th ose wh o sm oke 0.5 PPD.
Exp la n a tio n : Th ere is a 1 in th e co n id en ce in ter va l (CI) a t 0.5 PPD so a n a sso cia tio n
b etween sm o kin g a t th a t level a n d COPD ca n n o t b e d em o n stra ted . In co n tra st, th ere is n o
1 in th e co n id en ce in terva ls at 1.0 PPD or h igh er levels o sm okin g so a sta tistica lly sign i i-
ca n t a sso cia tio n a t th e 95% CI exists b etween sm okin g 1.0 or m o re PPD a n d COPD.
C. Categorical tests. To an alyze categorical d ata or com p are p rop ortion s, th e chi-square test
or Fisher’s e act test (wh en th e sam p le size is sm all) (Exam p le 26.1) is u sed .
312
Chapter 26 Statistical Analyses 313
16. For a grou p o 20 elderly p atien ts aged 85 17. At an Am erican m ed ical sch ool, a stu d y
to 90 years, blood p ressu re m easu rem en ts is don e to evalu ate th e relation sh ip between
are taken an d recorded th ree tim es p er day p aren tal in com e (in th ou san ds o d ollars p er
over a 2-week p eriod . At th e en d o th e 2 year) an d USMLE Step 1 scores. Wh ich o th e
weeks, th e p atien ts’ blood p ressu res are ollowin g is m ost likely to be th e correlation
taken an d record ed ou r tim es p er d ay or th e coe f cien t (r) or th is relation sh ip as sh own
n ext 2 weeks. I th e p atien ts’ b lood p ressu res by these data?
all with in a n orm al d istribu tion , wh at will
be th e e ect o takin g th e b lood p ressu res
e
240+
r
ou r tim es p er day rath er th an th ree tim es
o
c
240
S
p er d ay on th e stan d ard deviation an d sh ap e
1
220
p
o the resu ltin g cu rve?
e
200
t
S
(A) Stan d ard d eviation d ecreases; sh ap e o
E
180
L
M
th e cu rve d oes n ot ch an ge. 160
S
U
(B) Stan d ard d eviation in creases; sh ap e o 140
20 30 40 50 60 70 80 90 100+
th e cu rve d oes n ot ch an ge.
Pa re nta l income (in thous a nds of dolla rs )
(C) Stan d ard d eviation d ecreases; sh ap e o
th e cu rve is p ositively skewed . (A) 1.40
(D) Stan d ard d eviation in creases; sh ap e o (B) 0.50
th e cu rve is n egatively skewed. (C) 0
(E) Stan d ard d eviation d oes n ot ch an ge; (D) −0.25
sh ap e o th e cu rve d oes n ot ch an ge. (E) −0.75
An swers an d Exp lan ation s
1. The answer is D. 2. The answer is A. Th e estim ated stan dard error o th e m ean (SE) equ als
th e sam p le stan dard d eviation (18) divid ed by th e squ are root o 81 = 9. Th e SE is th ere ore
18/ 9 = 2. Con id en ce in terval (CI) sp eci ies th e in terval in wh ich th e tru e p op u lation m ean
lies. Th e CI is equ al to th e m ean o th e sam p le (X) p lu s or m in u s th e z score. Th e 95% CI an d
99% CI equal th e m ean plus or m in us 2.0 (SE) an d 2.5 (SE), resp ectively, th at is, 135 ± 4
(95% con iden ce in terval) an d 135 ± 5 (99% con iden ce in terval).
3. The answer is B. With resp ect to estim atin g th e m ean , p recision re lects h ow reliab le th e
estim ate is an d accu racy re lects h ow close th e estim ate is to th e tru e m ean . Th e wider
th e CI, th e less p recise an d th e m ore accu rate th e estim ate o th e m ean . Wh en com p ared
to a 99% con id en ce in terval, a 95% con id en ce in terval will be m ore p recise (sm aller
SE an d wid th o th e con iden ce in terval) bu t less accu rate (th e sam p le is less likely to be
rep resen tative).
4. The answer is B. 5. The answer is D. 6. The answer is D. Systolic blood p ressu re o 140
m m Hg is 2 stan dard d eviation s ab ove th e m ean (120 m m Hg). Th e area u n der th e cu rve
b etween 2 an d 3 stan dard d eviation s ab ove th e m ean is abou t 2.35% p lu s abou t 0.15%
(everyth in g ab ove 3 stan d ard deviation s). Th u s, a total o abou t 2.5% o th e p eop le will
h ave b lood p ressu res o 140 m m Hg an d above. Systolic blood p ressu re between 110 an d
120 m m Hg is 1 stan dard deviation below th e m ean . Th e p ercen tage o p eop le in th is area
on a n orm al cu rve is 34%. Th u s, 34% o 500 p eop le, or 170 p eop le, will h ave systolic blood
p ressu re in th e ran ge o 110–120 m m Hg. “With in” in cludes 1 stan dard deviation below
(34%) p lu s 1 stan dard d eviation above (34%) th e m ean or a total o 68%. Th u s, a total o
68% o th e p op u lation can be exp ected to h ave blood p ressu re th at alls with in 1 stan dard
d eviation o th e m ean .
7. The answer is C. Th e ch i-squ are test is u sed to exam in e d i eren ces b etween requ en cies in
a sam p le, in th is case, th e p ercen tage o wom en wh o lose weigh t on a p rotein -sp arin g diet
versu s th e p ercen tage o wom en wh o lose weigh t on a h igh -p rotein diet.
8. The answer is A. Th e t-test is u sed to exam in e di eren ces between m ean s o two sam p les.
Th is is an exam p le o a p aired t-test becau se th e sam e wom en are exam in ed on two
d i eren t occasion s.
9. The answer is D. Correlation is u sed to exam in e th e relation sh ip between two con tin u ou s
variables—in th is case, systolic blood p ressu re an d body weigh t.
315
316 BRS Behavioral Science
317
318 BRS Behavioral Science
32. Th e u su al stan d ard s o doctor–p atien t 36. An in an t’s ability to roll over rom back
con den tiality are m ost likely to ap p ly to to belly an d belly to b ack u su ally begin s at
wh ich o th e ollowin g p atien ts? wh at age?
(A) A m an wh o tells h is p h ysician th at h e (A) 0–3 m on th s
p lan s to sh oot h is p artn er (B) 4–6 m on th s
(B) A recen tly b ereaved wom an wh o tells h er (C) 7–10 m on th s
p h ysician th at sh e h as h ad occasion al (D) 12–15 m on th s
th ou gh ts o su icide (E) 16–30 m on th s
(C) A m an wh o tells h is p h ysician th at h e h as
been sexu ally ab u sin g h is 10-year-old 37. A p atien t in th e em ergen cy dep artm en t
step d au gh ter h as ju st been in volved in a car acciden t.
(D) An HIV-p ositive m an wh o is en gagin g in Th e p h ysician su sp ects th at sh e h as b een
sexu al in tercou rse with h is wi e with ou t drin kin g. In m ost states, th e lowest blood
u sin g con dom s alcoh ol con cen tration (BAC) to m eet th e
(E) A d ep ressed wom an wh o tells h er criterion or legal in toxication alls in to
p h ysician th at sh e h as saved u p 50 wh ich o th e ollowin g ran ges?
barb itu rate tablets an d wan ts to die (A) 0.01%–0.02%
33. Doctor A is aware th at Doctor B h as (B) 0.05%–0.15%
m ade a seriou s m istake in treatin g a very (C) 0.40%–0.50%
ill h osp italized p atien t. Doctor B re u ses (D) 1.5%–2.0%
to ad m it th at h e h as m ad e a m istake. Most (E) 2.5%–3.0%
ap prop riately, Doctor A sh ou ld
38. O th e ollowin g agen ts, wh ich is
(A) talk to Doctor B again abou t h is m istake
th e m ost ap p rop riate h eterocyclic
(B) warn Doctor B th at h e will be rep orted i
an tidep ressan t or a 45-year-old air tra c
h e con tin u es to m ake m istakes
con troller wh o m u st stay alert on th e
(C) rep ort Doctor B’s action to Doctor B’s
job?
su p erior at th e h osp ital
(D) rep ort Doctor B’s action to th e p olice (A) Selegilin e
(E) recom m en d th at Doctor B be tran s erred (B) Tran ylcyp rom in e
to an oth er h osp ital (C) Trazodon e
(D) Doxep in
34. To ollow im p rovem en t or d eterioration (E) Am oxap in e
over tim e in a 70-year-old p atien t with (F) Flu oxetin e
su sp ected n eu rologic dys u n ction , wh ich o (G) Protrip tylin e
th e ollowin g is th e m ost ap p rop riate test? (H) Nortrip tylin e
(A) Positron em ission tom ograp h y (PET) (I) Am itrip tylin e
(B) Com p u ted tom ograp h y (CT) (J ) Im ip ram in e
(C) Am obarbital sodiu m (Am ytal) in terview
(D) Th em atic ap p ercep tion test (TAT) 39. A 79-year-old wom an rep orts th at
(E) Electroen cep h alogram (EEG) sh e h as di cu lty sleep in g th rou gh th e
(F) Wid e Ran ge Ach ievem en t Test (WRAT) n igh t becau se o p ersisten t m u scu lar
(G) Folstein Min i–Men tal State Exam in ation con traction s in h er legs. Wh ich o th e
(H) Glasgow Com a Scale ollowin g sleep d isord ers b est m atch es th is
p ictu re?
35. To evalu ate u n con sciou s con f icts in a
20-year-old m an u sin g d rawin gs d ep ictin g (A) Klein e-Levin syn drom e
am bigu ou s social situ ation s, wh ich o th e (B) Nigh tm are disorder
ollowin g is th e m ost ap p rop riate test? (C) Sleep terror disord er
(D) Sleep dru n ken n ess
(A) Positron em ission tom ograp h y (PET) (E) Circadian rh yth m sleep disorder
(B) Com p u ted tom ograp h y (CT) (F) Noctu rn al m yoclon u s
(C) Am obarbital sodiu m (Am ytal) in terview (G) Restless legs syn d rom e
(D) Th em atic ap p ercep tion test (TAT)
(E) Electroen cep h alogram (EEG)
(F) Wid e Ran ge Ach ievem en t Test (WRAT)
(G) Folstein Min i–Men tal State Exam in ation
(H) Glasgow Com a Scale
322 BRS Behavioral Science
40. A p ilot wh ose p lan e is ab ou t to cra sh d ay. O th e ollowin g e ects, wh ich is m ost
sp en d s 5 m in u tes exp lain in g th e tech n ica l likely in th is p atien t?
d etails o th e en gin e m a l u n ction to h is (A) Blood p ressu re red u ction
cop ilot. Th e d e en se m ech a n ism th at th e (B) Leth argy
p ilot is u sin g to d eal with h is own (C) Tach ycardia
an xiety is (D) Decreased gastric acid secretion
(A) rep ression (E) Dep ressed m ood
(B) su b lim ation
(C) dissociation 45. Th e social sm ile com m on ly rst ap p ears
(D) regression at wh at age in typ ical in an ts?
(E) in tellectu alization (A) 0–3 m on th s
(B) 4–6 m on th s
41. Most typ ical ch ild ren b egin to walk (C) 7–10 m on th s
with ou t assistan ce at wh at age? (D) 12–15 m on th s
(A) 0–3 m on th s (E) 16–30 m on th s
(B) 4–6 m on th s 46. To evaluate readin g and arithm etic skills in
(C) 7–10 m on th s a 30-year-old hospitalized m ale patient, which
(D) 12–15 m on th s o the ollowin g is the m ost appropriate test?
(E) 16–30 m on th s
(A) Positron em ission tom ograp h y (PET)
42. A 40-year-old wom an with ten sion (B) Com p u ted tom ograp h y (CT)
h eadach es h as th e ten sion in th e ron talis (C) Am obarbital sodiu m (Am ytal) in terview
m u scle m easu red regu larly. Th e readin gs are (D) Th em atic ap p ercep tion test (TAT)
p rojected to h er on a com p u ter screen . Sh e (E) Electroen cep h alogram (EEG)
is th en tau gh t to u se m en tal tech n iqu es to (F) Wide Ran ge Ach ievem en t Test (WRAT)
decrease ten sion in th is m u scle. Wh ich o (G) Folstein Min i–Men tal State Exam in ation
th e ollowin g treatm en t tech n iqu es d oes th is (H) Glasgow Com a Scale
exam p le illu strate? 47. Th e EEG o a 32-year-old sleep in g p atien t
(A) Im p losion sh ows m ain ly slow waves. Wh at stage o
(B) Bio eed b ack sleep is th is p atien t m ost likely to be in ?
(C) Aversive con dition in g (A) Stage 1
(D) Token econ om y (B) Stage 2
(E) Floodin g (C) Stages 3 an d 4
(F) System ic desen sitization (D) REM
(G) Cogn itive th erapy
48. Typ ical in an ts b egin visu ally ollowin g
43. A p atien t rep orts th at d esp ite th e act aces an d objects with th eir eyes (trackin g) at
th at h e goes to sleep at 11:00 p m an d wakes wh at age?
u p at 7:00 a m , h e d oes n ot eel u lly awake (A) 0–3 m on th s
u n til ab ou t n oon each d ay. His wi e states (B) 4–6 m on th s
th at h e ap p ears to b e sleep in g sou n d ly (C) 7–10 m on th s
at n igh t. Th e p atien t d en ies su b stan ce u se, (D) 12–15 m on th s
an d p h ysical exam in ation is (E) 16–30 m on th s
n orm al. Wh ich o th e ollowin g sleep
d isord ers b est m atch es th is clin ical 49. A 65-year-old p h ysician wh o h as been
p ictu re? given a diagn osis o term in al p an creatic
(A) Klein e-Levin syn drom e can cer rep eatedly discu sses th e tech n ical
(B) Nigh tm are disorder asp ects o h is case with oth er p h ysician s in
(C) Sleep terror disord er th e h osp ital. Th e d e en se m ech an ism th at
(D) Sleep dru n ken n ess th is p h ysician is u sin g is
(E) Circadian rh yth m sleep disorder (A) actin g ou t
(F) Noctu rn al m yoclon u s (B) su b lim ation
(G) Restless legs syn d rom e (C) den ial
(D) regression
44. A 33-year-old p atien t tells th e p h ysician (E) in tellectu alization
th at h e d rin ks at least 10 cu p s o co ee p er (F) reaction orm ation
Comprehensive Examination 323
50. An an xiou s, d ep ressed teen ager, wh o h as (G) Avoidan t p erson ality disorder
n ever b een in trou b le be ore, steals a car. (H) Histrion ic p erson ality disorder
Th e de en se m ech an ism th at th is teen ager is
u sin g to m an age h is an xiety an d d ep ression 54. A 35-year-old m an com es to th e
is m ost likely to b e p h ysician’s o ce dressed all in brigh t yellow.
(A) actin g ou t He rep orts th at h e elt like h e h ad “a kn i e
(B) su b lim ation in h is ear” an d says th at h e is “b u rn in g u p”
(C) den ial an d “m u st be dyin g.” Ph ysical exam in ation
(D) regression reveals m ild otitis extern a (in f am m ation o
(E) in tellectu alization th e ear can al) an d tem p eratu re o 99.6°F. Th is
(F) reaction orm ation p atien t’s beh avior is m ost closely associated
with wh ich o th e ollowin g p erson ality
51. A 50-year-old h osp italized p atien t h as disorders?
ju st received a d iagn osis o breast can cer. (A) Passive–aggressive p erson ality disorder
Sh e states th at th e biop sy was in error an d (B) Sch izotyp al p erson ality disorder
ch ecks ou t o th e h osp ital again st th e advice (C) An tisocial p erson ality d isord er
o her p h ysician . Th e de en se m ech an ism (D) Paran oid p erson ality d isord er
th at th is p atien t is u sin g is (E) Sch izoid p erson ality disorder
(A) actin g ou t (F) Obsessive–com pulsive personality
(B) su b lim ation disorder
(C) den ial (G) Avoidan t p erson ality disorder
(D) regression (H) Histrion ic p erson ality disorder
(E) in tellectu alization
(F) reaction orm ation 55. A 24-year-old p atien t is exp erien cin g
in ten se h u n ger as well as tired n ess an d
52. A p atien t, alth ou gh sh e is u n con sciou sly h eadach e. Th is p atien t is m ost likely to be
an gry at h er p h ysician becau se h e can celed with d rawin g rom wh ich o th e ollowin g
h er p reviou s ap p oin tm en t at th e last m in u te, agen ts?
tells h im at h er n ext ap p oin tm en t th at sh e (A) Alcoh ol
really likes h is tie. Th e de en se m ech an ism (B) Secobarbital
th at th is p atien t is u sin g is (C) Ph en cyclidin e (PCP)
(A) actin g ou t (D) Am p h etam in e
(B) su b lim ation (E) Lysergic acid d ieth ylam ide (LSD)
(C) den ial (F) Diazep am
(D) regression (G) Heroin
(E) in tellectu alization (H) Mariju an a
(F) reaction orm ation
56. A 55-year-old m an , wh o h as been takin g
53. A 28-year-old wom an , wh o works as m edication s or dep ression an d in som n ia, is
an an im al caretaker, lives with h er eld erly brough t to th e em ergen cy dep artm en t with
au n t an d rarely socializes. Sh e rep orts th at, sign s o severe resp iratory dep ression . Th e
alth ou gh sh e wou ld like to h ave rien d s, agen t m ost likely to be resp on sible or th ese
wh en coworkers ask h er to join th em or sym p tom s is
b reaks, sh e re u ses b ecau se sh e is a raid (A) alcoh ol
th at th ey will criticize or n ot like h er. (B) secobarb ital
Th is b eh avior is m ost closely associated (C) p h en cyclidin e (PCP)
with wh ich o th e ollowin g p erson ality (D) am p h etam in e
d isorders? (E) lysergic acid dieth ylam ide (LSD)
(A) Passive–aggressive p erson ality d isord er (F) diazep am
(B) Sch izotyp al p erson ality disorder (G) h eroin
(C) An tisocial p erson ality d isord er (H) m ariju an a
(D) Paran oid p erson ality d isord er
(E) Sch izoid p erson ality disorder
(F) Obsessive–com pulsive personality
disorder
324 BRS Behavioral Science
57. Th e p olice brin g a 25-year-old m an to 61. A 24-year-old wom an exp erien ces p elvic
th e h osp ital in a com a. His girl rien d tells th e p ain wh en sh e an d h er boy rien d attem p t
p h ysician th at p rior to h avin g a seizu re, h e to h ave sexu al in tercou rse. No ab n orm alities
becam e com b ative, sh owed abn orm al eye are ou n d du rin g p elvic exam in ation . O th e
m ovem en ts, an d said th at h e elt h is body ollowin g, th e m ost ap p rop riate diagn osis
exp an din g an d f oatin g u p to th e ceilin g. or th is p atien t is
O th e ollowin g, th e dru g m ost likely to be (A) etish ism
resp on sib le or th ese sym p tom s is (B) gen itop elvic p ain / p en etration disorder
(A) alcoh ol (C) sexu al in terest/ arou sal disord er
(B) secobarb ital (D) orgasm ic disorder
(C) p h en cyclid in e (PCP) (E) gen der dysp h oria
(D) am p h etam in e
(E) lysergic acid dieth ylam ide (LSD) 62. A 65-year-old wom an wh ose h u sb an d
(F) diazep am d ied 3 weeks ago rep orts th at sh e cries
(G) h eroin o ten an d sleep s p oorly. Also, sh e states
(H) m ariju an a th at alth ou gh sh e kn ows h er h u sb an d is
d ead , sh e th ou gh t th at sh e saw h im walkin g
58. A p atien t wh o h as been a h eavy co ee d own th e street th e d ay b e ore. Th e m ost
drin ker is h osp italized an d n ot p erm itted to ap p rop riate rst action by h er p h ysician is
take an yth in g excep t water by m ou th . Wh ich to
o the ollowin g is th e p atien t m ost likely to (A) recom m en d th at sh e visit a close
dem on strate th e d ay a ter h osp italization ? relative
(A) Excitem en t (B) p rovide su p p ort an d reassu ran ce
(B) Eu p h oria (C) p rescribe an tip sych otic m edication
(C) Headach e (D) p rescribe an tidep ressan t m edication
(D) Decreased ap p etite (E) recom m en d a p sych iatric evalu ation
(E) Pu p il d ilation
63. Wh ich o th e ollowin g in dividu als
59. A 50-year-old em ale stroke p atien t h as th e h igh est risk or develop in g
op en s h er eyes in resp on se to a verb al sch izop h ren ia?
com m an d , sp eaks bu t u ses in ap p rop riate (A) Th e dizygotic twin o a p erson with
word s, an d sh ows f exion to p ain u l stim u lu s. sch izop h ren ia
For th ese resp on ses, sh e receives a test score (B) Th e ch ild o two p aren ts with
o 9. Wh ich o th e ollowin g is m ost likely to sch izop h ren ia
be th e test th at was u sed? (C) Th e m on ozygotic twin o a p erson with
(A) Positron em ission tom ograp h y (PET) sch izop h ren ia
(B) Com p u ted tom ograp h y (CT) (D) Th e ch ild o on e p aren t with
(C) Am obarbital sodiu m (Am ytal) in terview sch izop h ren ia
(D) Th em atic ap p ercep tion test (TAT) (E) A ch ild raised in an in stitu tion al set-
(E) Electroen cep h alogram (EEG) tin g wh en n eith er biological p aren t h ad
(F) Wid e Ran ge Ach ievem en t Test (WRAT) sch izop h ren ia
(G) Folstein Min i–Men tal State Exam in ation
(H) Glasgow Com a Scale 64. Wh ich o th e ollowin g statem en ts is
m ost likely to be eviden ce o p sych otic
60. Th e electroen cep h alogram o a 28-year- eatu res in a severely dep ressed 49-year-old
old p atien t sh ows m ain ly alp h a waves. Th is m an ?
p atien t is m ost likely to b e (A) “I am an in ad equ ate p erson .”
(A) awake an d con cen tratin g (B) “I am a worth less h u m an bein g.”
(B) awake, relaxed, with eyes closed (C) “I will n ever get better.”
(C) in stage 1 sleep (D) “I am a ailu re in m y p ro ession .”
(D) in delta sleep (E) “I am p erson ally resp on sib le or th e
(E) in REM sleep Tsu n am i in Jap an .”
Comprehensive Examination 325
65. A ter a li e-th reaten in g b icycle acciden t, 69. Wh ich o th e ollowin g con dition s
a 9-year-old ch ild requ ires an im m ed iate com m on ly rst becom es ap p aren t in th e
b lood tran s u sion . I , or religiou s reason s, ou rth or th d ecade o li e?
th e p aren ts re u se to allow th e tran s u sion , (A) Alzh eim er’s d isease
th e p h ysician sh ou ld (B) Lesch -Nyh an syn drom e
(A) tell th e p aren ts th ey will be p rosecu ted i (C) Rett’s d isord er
th ey do n ot allow th e tran s u sion (D) Tou rette’s disorder
(B) give th e ch ild th e tran s u sion (E) Hu n tin gton’s disease
(C) ob tain p erm ission rom an oth er am ily
m em b er to d o th e tran s u sion 70. Du rin g an op h th alm ologic exam in ation ,
(D) h ave th e ch ild m oved to an oth er a 48-year-old em ale p atien t, wh o h as h ad
h osp ital sch izop h ren ia or m ore th an 30 years, is
(E) ollow th e p aren ts’ in stru ction s an d do ou n d to h ave retin al p igm en tation . In th e
n ot give th e ch ild th e tran s u sion p ast, th is p atien t is m ost likely to h ave taken
wh ich on e o th e ollowin g an tip sych otic
66. A p atien t states th at ever sin ce a agen ts?
lon gtim e lover called to b reak u p th eir
(A) Ch lorp rom azin e
relation sh ip, th e p atien t h as h ad a severe
(B) Halop eridol
h earin g loss. No m ed ical exp lan ation can b e
(C) Perp h en azin e
ou n d . Wh ich o th e ollowin g is m ost likely
(D) Tri lu op erazin e
to be tru e ab ou t th is p atien t?
(E) Th ioridazin e
(A) Th e p atien t is old.
(B) Th e p atien t is m ale. 71. A typ ical 24-year-old wom an wh o is in
(C) Th e p atien t is well edu cated. n on -REM sleep is m ost likely to sh ow wh ich
(D) Th e p atien t’s h earin g loss ap p eared o the ollowin g?
su d den ly.
(A) Dream in g
(E) Th e p atien t is very u p set ab ou t th e h ear-
(B) In creased p u lse
in g loss.
(C) Clitoral erection
67. Lon g-term p sych iatric h osp itals in (D) Skeletal m u scle aton y
th e Un ited States are own ed an d op erated (E) Delta waves on th e
p rim arily by electroen cep h alogram
(A) u n iversities
72. O th e ollowin g d isorders, th e on e m ost
(B) p rivate in vestors
likely to sh ow th e largest sex d i eren ce in its
(C) state govern m en ts
occurren ce is
(D) m u n icip al govern m en ts
(E) th e ederal govern m en t (A) cycloth ym ic disorder
(B) m ajor dep ressive disorder
68. A 60-year-old jan itor rom New York, wh o (C) bip olar disord er
recen tly lost h is job as a teach er, is ou n d in (D) illn ess an xiety disorder
Akron , Oh io, workin g as a salesm an . He does (E) sch izop h ren ia
n ot kn ow h ow h e arrived th ere, an d p h ysical
exam in ation is u n rem arkable. O th e 73. Negative p redictive valu e is th e
ollowin g, th e m ost ap p rop riate diagn osis or p robab ility th at a p erson with a
th is m an is (A) n egative test is actu ally well
(A) dissociative am n esia (B) p ositive test is actu ally well
(B) dissociative am n esia with u gu e (C) n egative test is actu ally ill
(C) som atic sym p tom disorder (D) p ositive test is actu ally ill
(D) con version d isorder (E) p ositive test will even tu ally sh ow sign s o
(E) dep erson alization disorder th e illn ess
326 BRS Behavioral Science
74. In a laboratory stu dy, it is sh own th at the carried to term u sed LCDCS du rin g th eir
uterus rises in the pelvic cavity durin g sexu al p regn an cies, th e odds–risk ratio associated
activity. In which stage o the sexual respon se with LCDCS in p regn an cy is ap p roxim ately
cycle does this phen om en on rst occur? (A) 2
(A) Excitem en t (B) 3
(B) Plateau (C) 10
(C) Orgasm (D) 20
(D) Resolu tion (E) 100
75. A cou p le tells th e p h ysician th at th eir 79. In a coh ort stu dy, th e ratio o th e
sex li e h as been p oor becau se th e m an in cid en ce rate o m iscarriage am on g wom en
ejacu lates too qu ickly. Th e p h ysician tells wh o u se LCDCS to th e in cid en ce rate o
th em th at th e “squ eeze tech n iqu e” wou ld b e m iscarriage am on g wom en wh o do n ot u se
h elp u l. In th is tech n iqu e, th e p erson wh o LCDCS is th e
ap plies th e “squ eeze” is u su ally (A) attrib u tab le risk
(A) th e m an (B) odds–risk ratio
(B) th e p artn er (C) in ciden ce rate
(C) th e p h ysician (D) p revalen ce ratio
(D) a sex th erap ist (E) relative risk
(E) a sex su rrogate
Questions 80 and 81
76. Wh ich o th e ollowin g statistical tests
is m ost ap p rop riately u sed to evalu ate In a stu dy, th e in ciden ce rate o tu bercu losis
di eren ces am on g m ean b ody weigh ts o (TB) in p eop le wh o h ave som eon e with TB
wom en in th ree di eren t age grou p s? livin g in th eir h om e is 5 p er 1,000. Th e in ci-
den ce rate o TB in p eop le wh o h ave n o on e
(A) Dep en den t (p aired ) t-test
with TB livin g in th eir h om e is 0.5 p er 1,000.
(B) Ch i-squ are test
(C) An alysis o varian ce
80. Wh at is th e risk or gettin g TB
(D) In dep en den t (u n p aired) t-test
attribu table to livin g with som eon e wh o h as
(E) Fish er exact test
TB (attribu table risk)?
77. A 39-year-old m an (wh o h as n ever be ore (A) 1.5
h ad p rob lem s with erection s) b egin s to h ave (B) 4.5
di cu lty ach ievin g an erection du rin g sexu al (C) 7.5
activity with h is wi e. Th e very rst tim e h e (D) 9.5
h ad trou ble m ain tain in g an erection was (E) 10.0
a ter a beach p arty wh en h e h ad “too m u ch
to drin k.” Th is m an is sh owin g evid en ce o 81. How m an y tim es h igh er is th e risk o
wh ich o th e ollowin g sexu al d ys u n ction s? gettin g TB or p eop le wh o live with a p atien t
with TB th an or p eop le wh o d o n ot live with
(A) Acqu ired erectile d isord er a TB p atien t (th e relative risk)?
(B) Situ ation al erectile disorder
(C) Delayed ejacu lation (A) 1.5
(D) Orgasm ic d isord er (B) 4.5
(E) Prem atu re ejacu lation (C) 7.5
(D) 9.5
(E) 10.0
78. A stu dy was carried ou t to d eterm in e
wh eth er exp osu re to liqu id crystal disp lay
82. To estim ate th e relative risk in a case–
com p u ter screen s (LCDCS) in th e rst
con trol stu dy, wh ich o th e ollowin g is
trim ester o p regn an cy resu lts in m iscarriage.
calcu lated?
To do th is, 50 wom en wh o h ad m iscarriages
an d 90 wom en wh o carried to term were (A) Attrib u tab le risk
qu estion ed th e d ay a ter m iscarriage or (B) Odds–risk ratio
delivery, resp ectively, ab ou t th eir exp osu re (C) In ciden ce rate
to LCDCS d u rin g p regn an cy. I 10 wom en (D) Prevalen ce ratio
wh o h ad m iscarriages an d 10 wom en wh o (E) Sen sitivity
Comprehensive Examination 327
83. A 50-year-old em ale h igh sch ool teach er 87. “Man y p eop le eel th e way you do wh en
wh o had been o n orm al weigh t rep orts that th ey rst n eed h osp italization” is an exam p le
she has been “ eelin g very low” or the past 3 o the in terview tech n iqu e kn own as
m on ths. She o ten m isses work because she (A) con ron tation
eels tired an d h op eless, h as lost 20 p oun ds (B) valid ation
withou t dietin g, an d h as trou ble sleep in g. (C) recap itu lation
Wh en the p hysician in terviews h er, sh e says, (D) acilitation
“Doctor, th e Lord calls all h is ch ildren h om e.” (E) re lection
Physical n din gs are un rem arkable. This (F) direct qu estion
clin ical p icture is m ost closely associated with (G) su p p ort
(A) cycloth ym ic disord er
(B) m ajor dep ressive d isord er 88. A ter a patient has described his sym ptom s
(C) bip olar disord er an d the tim e o day that they intensi y, the
(D) illn ess an xiety disorder interviewer says, “You say that you elt the
(E) sch izop h ren ia pain m ore in the evening?” This question is an
exam ple o the interview technique known as
84. A 32-year-old m an su rvives a p lan e (A) con ron tation
crash in wh ich ou r p assen gers died. Two (B) valid ation
weeks later, h e rep orts th at h e h as recu rrin g (C) recap itu lation
n igh tm ares ab ou t th e crash an d eels (D) acilitation
isolated an d distan t rom oth ers. Th is p atien t (E) re lection
is m ost likely to h ave wh ich o th e ollowin g (F) direct qu estion
d isord ers? (G) su p p ort
(A) Posttrau m atic stress disorder (PTSD) 89. “You say th at you are n ot n ervou s, bu t
(B) Gen eralized an xiety disorder you are sweatin g an d sh akin g an d seem
(C) Obsessive–com p u lsive disord er (OCD) very u p set to m e” is an exam p le o th e
(D) Pan ic disorder in terviewin g tech n iqu e kn own as
(E) Acu te stress disorder
(A) con ron tation
(B) valid ation
85. On e year a ter sh e was robb ed at
(C) recap itu lation
kn i ep oin t in th e street, a 28-year-old wom an
(D) acilitation
ju m p s at every lou d n oise, h as recu rren t
(E) re lection
th ou gh ts ab ou t th e rob b ery, an d is an xiou s
(F) direct qu estion
m u ch o th e tim e. O th e ollowin g, th e best
(G) su p p ort
d iagn osis or th is p atien t is
(A) p osttrau m atic stress disorder (PTSD) 90. A p atien t relates to th e p h ysician , “I I am
(B) gen eralized an xiety disorder seated at a table in th e cen ter o a restau ran t
(C) ob sessive–com p u lsive d isord er (OCD) rath er th an again st th e wall, I su d den ly get
(D) p an ic disorder dizzy an d eel like I can n ot breath e.” Th is
(E) acu te stress disorder p atien t is d escribin g a(n )
(A) h allu cin ation
86. At th e close o a lon g in terview with an (B) delu sion
elderly m ale p atien t, th e p h ysician says “Let’s (C) illu sion
see i I h ave taken all o th e in orm ation (D) p an ic attack with agorap h obia
correctly” an d th en su m s u p th e in orm ation (E) social an xiety disorder
th at th e p atien t h as given . Th is in terviewin g
tech n iqu e is kn own as 91. A p atien t relates to the p hysician , “Last
(A) con ron tation week, I thought I saw m y ather who died last
(B) valid ation year go aroun d the corn er, but I kn ow it wasn’t
(C) recap itu lation really him .” This p atien t is describin g a(n )
(D) acilitation (A) h allu cin ation
(E) re lection (B) delu sion
(F) direct qu estion (C) illu sion
(G) su p p ort (D) p an ic attack with agorap h obia
(E) social an xiety disorder
328 BRS Behavioral Science
92. Th e m ost ap p rop riate m eth od to wom an’s sp ou se rep orts th at sh e sn ores
determ in e th e p art o th e b rain u sed du rin g lou dly. Th is wom an is sh owin g evid en ce o
th e tran slation o a written p assage rom (A) n arcolep sy
Fren ch to En glish is (B) Klein e-Levin syn drom e
(A) com p u ted tom ograp h y (CT) (C) in som n ia
(B) dexam eth ason e su p p ression test (DST) (D) ob stru ctive sleep ap n ea
(C) evoked p oten tials (E) sleep terror d isorder
(D) electroen cep h alogram (EEG)
98. Followin g th e loss o h er job as a
(E) galvan ic skin resp on se
cash ier, a 23-year-old p atien t rep orts, in a
(F) p ositron em ission tom ograp h y (PET)
d ispassion ate way, th at sh e h as n o sen sation
in h er righ t arm . Ph ysical exam in ation ails
93. Th e m ost ap p rop riate diagn ostic
to reveal a p h ysiological p rob lem . Th is
tech n iqu e to evalu ate h earin g loss in a
p atien t is sh owin g evid en ce o
3-m on th -old in an t is
(A) illn ess an xiety disorder
(A) com p u ted tom ograp h y (CT)
(B) bod y d ysm orp h ic d isord er
(B) dexam eth ason e su p p ression test (DST)
(C) con version disorder
(C) evoked p oten tials
(D) som atic sym p tom disorder
(D) electroen cep h alogram (EEG)
(E) gen eralized an xiety disorder
(E) galvan ic skin resp on se
(F) p ositron em ission tom ograp h y (PET) 99. Desp ite th e p h ysician’s reassu ran ces an d
n egative biop sies o ve di eren t m oles, a
94. A 42-year-old wom an p reten ds th at sh e is 45-year-old p atien t ap p ears very worried
p aralyzed ollowin g an au tom ob ile accid en t an d tells th e p h ysician th at h e believes th at
in ord er to collect m on ey rom th e in su ran ce h is rem ain in g m oles sh ou ld be b iop sied
com p an y. Th is wom an is dem on stratin g b ecau se th ey are “p robably m elan om as.”
(A) derealization Th is p atien t is sh owin g evid en ce o
(B) actitiou s disorder (A) illn ess an xiety disorder
(C) m alin gerin g (B) bod y d ysm orp h ic d isord er
(D) con version d isorder (C) con version disorder
(E) bod y d ysm orp h ic d isord er (D) som atic sym p tom disorder
(E) gen eralized an xiety disorder
95. A 42-year-old wom an p reten d s th at
sh e is p aralyzed ollowin g an au tom obile 100. A d og learn s to tu rn a d oorkn ob with
acciden t in order to gain atten tion rom h er its teeth becau se th is beh avior h as been
p h ysician . Th is p atien t is d em on stratin g rewarded with a treat. Th is is an exam p le o
th e typ e o learn in g best described as
(A) derealization
(B) actitiou s disorder (A) op eran t con d ition in g
(C) m alin gerin g (B) aversive con dition in g
(D) con version d isorder (C) sp on tan eou s recovery
(E) bod y d ysm orp h ic d isord er (D) m odelin g
(E) stim u lu s gen eralization
96. A 54-year-old wom an wh o is d ep ressed 101. Each tim e a 35-year-old m an receives
awaken s at 4:00 a m every m orn in g an d ph ysical th erapy or a sh oulder in ju ry, his
can n ot all back asleep. Sh e is th en tired all pain lessen s. Becau se o th is im p rovem en t
day. Th is wom an is m ost likely to h ave wh ich in pain , the patien t return s or m ore physical
o th e ollowin g sleep d isord ers? therapy session s. Th is p atien t’s in crease in
(A) Narcolep sy ph ysical th erapy session s is an exam p le o
(B) Klein e-Levin syn drom e which o the ollowin g?
(C) In som n ia (A) Im p losion
(D) Obstru ctive sleep ap n ea (B) Stim u lu s gen eralization
(E) Sleep terror disord er (C) System atic desen sitization
(D) Floodin g
97. A 40-year-old wom an wh o is overweigh t (E) Positive rein orcem en t
rep orts th at sh e eels tired all day d esp ite (F) Fixed ratio rein orcem en t
h avin g 9 h ou rs o sleep each n igh t. Th e (G) Negative rein orcem en t
Comprehensive Examination 329
111. Th e p a ren ts o a 17-yea r-old you n g d evelop m en t, resp ectively, th is ch ild is best
wo m an with Down’s syn d rom e a n d a n d escribed as
in telligen ce q u otien t (IQ) o 70 b rin g h er (A) typ ical, typ ical, n eeds evalu ation
in or a sch ool p h ysica l. Th e p h ysica l (B) typ ical, n eeds evalu ation , typ ical
exam in a tio n is req u ired o r ad m ission to (C) n eeds evalu ation , typ ical, typ ical
a h igh ly recom m en d ed sp ecia l ed u ca tion (D) needs evaluation , n eeds evaluation , typical
co-ed b oa rd in g sch o ol. Th e p a ren ts a re (E) typ ical, typ ical, typ ical
wo rried a b ou t sen d in g th eir d a u gh ter (F) n eeds evalu ation , n eeds evalu ation ,
to th e sch o ol b eca u se sh e is sexu a lly n eeds evalu ation
active a n d th ey are a ra id th at sh e will (G) typical, n eeds evaluation , needs evaluation
get p regn a n t. Alth ou gh sh e h a s b een on
ora l co n tra cep tives o r th e p a st yea r, h er 115. A typ ical b oy can walk u p stairs 1 oot at
m oth er m u st o ten rem in d h er to ta ke a tim e, bu t wh en told to copy a circle, h e ju st
th em . Th e p a ren ts a sk or th e p h ysicia n’s scrib bles on p ap er. At th e p laygrou n d , h e
ad vice. Th e p h ysicia n’s m o st a p p rop ria te o ten m oves away rom h is m oth er to watch
recom m en d a tion is to th e oth er ch ildren , bu t th en com es righ t
(A) do a tu b al ligation back to h er. With resp ect to verbal skills, th is
(B) do an oop h orectom y ch ild is m ost likely to be ab le to
(C) en roll h er in a local day sch ool so th at (A) sp eak in com p lete sen ten ces
sh e can live at h om e (B) u se abou t 900 words
(D) p rescrib e a lon g-actin g con tracep tive (C) u se p rep osition s
(E) sen d h er to th e board in g sch ool an d take (D) u n derstan d abou t 3,500 words
n o u rth er action (E) u se abou t 10 words
112. A 6-year-old ch ild with an in telligen ce 116. As a 60-year-old m ale p atien t is leavin g
qu otien t (IQ) o 50 is m ost likely to be able to th e hosp ital a ter su rgery or p rostate can cer,
do wh ich o th e ollowin g? h e turn s to th e p h ysician an d says, “You
kn ow doctor, I h ave a gu n in m y h ou se.” Th e
(A) Read a sen ten ce m ost ap p rop riate action or th e p h ysician to
(B) Iden ti y colors take at th is tim e is to
(C) Copy a trian gle
(D) Ride a two-wh eeled b icycle (A) call th e p atien t’s wi e an d tell h er to in d
(E) Un d erstan d th e m oral di eren ce th e gu n an d rem ove it
between righ t an d wron g (B) su ggest th at th e p atien t rem ain in th e
h osp ital or u rth er evalu ation
113. A p h ysician diagn oses gen ital h erp es in (C) give th e p atien t a p rescrip tion or an
a 16-year-old m ale h igh sch ool stu d en t. Prior an tid ep ressan t
to treatin g h im , th e p h ysician sh ou ld (D) warn th e p atien t abou t takin g m edica-
tion s th at are dan gerou s in overdose
(A) n oti y h is p aren ts (E) release th e p atien t rom th e h osp ital as
(B) get p erm ission rom h is p aren ts p lan n ed
(C) n oti y h is sexu al p artn er(s)
(D) recom m en d th at h e tell h is sexu al 117. A b on d trader states th at som etim es
p artn er(s) h e m akes m on ey an d som etim es h e loses
(E) n oti y th e ap p rop riate state agen cy m on ey. Th e trader com p lain s th at h e is so
p reoccu p ied with tradin g bon ds th at h e
114. A 9-m on th -old in an t is b rou gh t to a can n ot seem to stop ollowin g th e b on d
p ediatrician by h is m oth er. Th e ch ild can sit m arkets, even on weeken ds wh en th e
u n assisted an d p u ll h im sel u p to stan d. He m arkets are closed . Wh ich o th e ollowin g
bab bles an d m akes n oises wh en h is m oth er is m ost likely to h ave in f u en ced th is trader’s
sp eaks to h im , bu t h e can n ot say an y word s. p reoccu p ation with tradin g bon ds?
Th e m oth er tells th e p h ysician th at wh en th e (A) Con tin u ou s rein orcem en t
ch ild sees h is b abysitter on Satu rd ay n igh ts, (B) Fixed ratio rein orcem en t
h e cries an d re u ses to go to h er. With resp ect (C) Fixed in terval rein orcem en t
to p h ysical, social, an d cogn itive/ verbal (D) Variab le ratio rein orcem en t
(E) Stim u lu s gen eralization
Comprehensive Examination 331
126. An eld erly Am erican wom an is m ost 130. A wom an wh o h ad a n orm al delivery o
likely to sp en d m ost o th e last 5 years o a n orm al ch ild 2 d ays ago tells h er p h ysician
h er li e th at sh e eels sad an d cries or n o reason .
(A) in a n u rsin g h om e Sh e ap p ears well groom ed an d is takin g
(B) with am ily con gratu latory calls an d visits rom rien ds
(C) on h er own an d am ily. Her p h ysician sh ou ld
(D) in a h osp ice (A) tell h er to stop worryin g
(E) in a h osp ital (B) h ave h er call h im daily over th e n ext 2
weeks to rep ort h ow sh e is eelin g
127. Th e h u sb an d o an 85-year-old (C) recom m en d a con su ltation with a
p atien t with Alzh eim er’s d isease tells th e p sych iatrist
p h ysician th at h e wan ts to keep h is wi e (D) p rescribe an an tidep ressan t
at h om e b u t is worried b ecau se sh e keep s (E) p rescribe a ben zodiazep in e
wan d erin g ou t th e ron t d oor o th e h ou se.
O th e ollowin g, th e m ost ap p rop riate 131. Alth ou gh tran sp lan ts can save m an y
recom m en d ation or th e p h ysician to m ake lives, th ere are ewer tran sp lan ts don e th an
at th is tim e is to are n eeded. O th e ollowin g, th e p rim ary
reason or th is is th at
(A) p lace th e p atien t in restrain ts
(B) label all th e doors as to th eir u n ction (A) th ere are n ot en ou gh don ors
(C) p rescribe diazep am (Valiu m ) (B) p atien ts are u su ally too ill to with stan d
(D) p rescribe don ep ezil (Aricep t) su rgery
(E) p lace th e p atien t in a n u rsin g h om e (C) tran sp lan ts are too exp en sive
(D) tran sp lan ts h ave a h igh ch an ce o
rejection
128. An 8-year-old ch ild with n orm al
(E) th e dru gs u sed to p reven t rejection are
in telligen ce reads, com m u n icates well, an d
too toxic
gets alon g well with th e oth er ch ildren in
sch ool. However, h e o ten argu es with th e
132. A 22-year-old m edical stu den t h as
teach er an d gets bad m arks or h is beh avior.
a p arotid glan d abscess an d an excessive
His p aren ts tell th e p h ysician th at h e o ten
n u m ber o den tal caries. Sh e is o n orm al
also seem s an gry toward th em an d rarely
weigh t or h er h eigh t, b u t seem s d istressed
ollows th eir ru les. Th e best descrip tion or
wh en th e p h ysician qu estion s h er abou t h er
th is ch ild’s beh avior is
eatin g h abits. Th is you n g wom an is m ost
(A) typ ical likely to h ave
(B) atten tion de icit h yp eractivity d isord er
(A) bu lim ia n ervosa
(ADHD)
(B) an orexia n ervosa
(C) au tism sp ectru m d isorder
(C) con version disorder
(D) op p osition al d e ian t d isord er
(D) avoidan t p erson ality d isord er
(E) con d u ct d isord er
(E) p assive–aggressive p erson ality disorder
129. Wh ich o th e o llowin g a gen ts is 133. Th e adop tive p aren ts o a n ewborn ask
m ost u se u l in th e m an agem en t o a th eir p h ysician wh en th ey sh ou ld tell th e
28-yea r-o ld m ale p atien t wh o exp erien ces ch ild th at sh e is adop ted . Th e p ediatrician
ca tap lexy, h yp n a gogic h a llu cin a tio n s, an d correctly su ggests th at th ey tell h er
a very sh o rt ra p id eye m ovem en t (REM)
(A) wh en sh e qu estion s th em abou t h er
la ten cy?
backgrou n d
(A) A b en zod iazep in e (B) wh en sh e en ters sch ool
(B) A b arb itu rate (C) as soon as sh e can u n d erstan d lan gu age
(C) An op ioid (D) at 4 years o age
(D) An an tip sych otic (E) i sh e develop s an illn ess th at h as a
(E) An am p h etam in e kn own gen etic b asis
Comprehensive Examination 333
148. A 21-year-old stu d en t rep orts th at disch arge rom th e n ip p les. Wh ich o th e
h e becom es very an xiou s wh en h e m u st ollowin g agen ts is m ost likely to b e th e n ew
u se a p u blic restroom bu t oth erwise does m edication ?
n ot rep ort ep isodes o an xiety. Becau se h e (A) Arip ip razole (Abili y)
becom es so u n com ortab le ab ou t u sin g (B) Olan zap in e (Zyp rexa)
p u blic restroom s, h e re u ses wh en h is (C) Zip rasid on e (Geodon )
classm ates ask h im to join th em wh en th ey (D) Ilop eridon e (Fan ap t)
go out. O th e ollowin g p h arm acologic (E) Risp eridon e (Risp erdal)
agen ts wh ich is b est or th e lon g-term
m an agem en t o th is stu den t’s sym p tom s is 152. A 43-year-old wom an rep orts th at sin ce
(A) im ip ram in e (To ran il) bein g p u t on an an tid ep ressan t, sh e h as
(B) ch lordiazep oxid e (Libriu m ) started to h ave di cu lty h avin g an orgasm .
(C) clom ip ram in e (An a ran il) Th e m edication th at th is p atien t is m ost
(D) ven la axin e (E exor) likely to be takin g is
(E) clon azep am (Klon op in ) (A) sertralin e
(B) vilazodon e
149. A 17-year-old college stu den t com es to
(C) m irtazap in e
th e ph ysician com p lain in g o acial swellin g
(D) du loxetin e
an d p ain . Th e stu d en t h as a BMI o 16, an d
(E) bu p rop ion
p h ysical exam in ation reveals a p arotid glan d
(F) ven la axin e
abscess. Th e p atien t n otes th at sh e on ly eats
h ealth y “diet” oods an d th en tells th e doctor
153. A 36-year-old p atien t tells th e p h ysician
th at som etim es sh e eels like h er eatin g is
th at sh e is h avin g di cu lt allin g asleep.
“ou t o con trol.” Th is clin ical p ictu re m ost
Wh ile th e p h ysical exam in ation is essen tially
closely su ggests
u n rem arkable, it reveals th at th e p atien t
(A) an orexia n ervosa is abou t 8 weeks p regn an t. I th e doctor
(B) bin ge-eatin g d isorder decides to p rescribe som eth in g to h elp th e
(C) bu lim ia n ervosa p atien t all asleep, wh ich o th e ollowin g
(D) illn ess an xiety disorder agen ts sh ou ld be avoided?
(E) acu te stress disorder
(A) Tem azep am
150. Paren ts o a 45-year-old , m ild ly (B) Bu sp iron e
in tellectu ally disabled p atien t tell th e doctor (C) Zolp id em
th at th e p atien t h as recen tly started to (D) Bu p rop ion
exp erien ce m em ory loss. Th e d octor n otes (E) Zalep lon
th at th e p atien t h as odd acial eatu res.
Th e gen etic abn orm ality resp on sible or 154. Five h ou rs a ter b irth , a m a le in an t
th is clin ical p ictu re is m ost likely to be on b egin s to sh ow excessive sa liva tion a n d
ch rom osom e la crim ation . Th e d o ctor n o tes th a t th e
ch ild , wh o h as a rap id h eart rate an d
(A) 1
ap p ears restless an d agitated , is sweatin g,
(B) 14
alth ou gh th e room is cool. Prior to
(C) 19
d elivery, th e m oth er o th is in an t is m ost
(D) 21
likely to h ave u sed wh ich o th e ollowin g
(E) 22
su b sta n ces?
151. Sin ce bein g started on a n ew (A) PCP
an tip sych otic m ed ication , a 25-year-old (B) Cocain e
em ale p atien t h as begu n to exp erien ce (C) Mariju an a
abn orm al m otor m ovem en ts. Sh e also (D) Alcoh ol
rep orts th at sh e h as started to h ave a (E) Heroin
336 BRS Behavioral Science
155. A 70-year old m an , wh o, over th e p ast Th e m ost likely exp lan ation or th is clin ical
year, h as d evelop ed m em ory loss, sp atial p ictu re is
im p airm en t, an d lan gu age di cu lties, (A) m ajor dep ressive disorder
h as recen tly started to sh ow a n e trem or (B) adju stm en t disord er
an d gait d istu rb an ces. Th e p atien t tells th e (C) gen eralized an xiety disorder
doctor th at h e is also d istu rb ed by vivid (D) typ ical “h om esickn ess”
visu al h allu cin ation s. Th e p atien t’s wi e (E) acu te stress disorder
rep orts th at at n igh t, th e p atien t is very
restless du rin g sleep an d o ten h its an d 158. A 48-year-old m an wh o h as been
p u n ch es h er. Two days a ter bein g started em p loyed by a com p an y or th e p ast 2 years
on risp eridon e to con trol th e h allu cin ation s, believes th at, alth ou gh th ey den y it, h is
th e p atien t b egin s to sh ow severe m u scu lar ellow em p loyees are con sp irin g to get h im
rigid ity. Asid e rom th ese sym p tom s, red. He believes th at th ey h ave wires on
p h ysical n din gs an d laboratory stu dies are h is p hon e an d th at th ey ollow h im h om e.
u n rem arkable. Th is clin ical p ictu re is m ost He requ en tly ch ecks h is h om e or cam eras
con sisten t with th at h e believes h is ellow em p loyees h ave
(A) deliriu m h idden th ere an d in sists th at h is wi e also
(B) Hu n tin gton’s disease ch eck wh en h e is at work. He den ies h avin g
(C) n eu rocogn itive d isorder with Lewy au ditory h allu cin ation s an d, asid e rom
bod ies th e con sp iracy idea, h as n o eviden ce o a
(D) Alzh eim er’s d isease th ou gh t disorder. Wh ich o th e ollowin g is
(E) acqu ired im m u n od e icien cy syn d rom e th e m ost ap p rop riate diagn osis or th is m an ?
(A) Sch izop h ren ia
156. A 34-year-old em ale p olice o cer (B) Bip olar d isord er
com es to th e p h ysician or a yearly (C) Delu sion al d isord er
p h ysical. Th e o cer tells th e d octor th at (D) Paran oid p erson ality d isord er
sh e sm okes on e-h al p ackage o cigarettes (E) Sch izoid p erson ality disorder
a d ay, eats h am b u rger an d steak at least
twice a week, an d d rin ks on e glass o red 159. A 55-year-old wom an presen ts in
win e d aily with d in n er. Sh e also n otes th at the em ergen cy room with orthostatic
wh ile sh e wears a seat b elt in th e p atrol car, h yp oten sion an d p rolon ged QT in terval. The
sh e rarely wears a seat b elt in h er own car. p atien t tells the ph ysician that th e previous
Th e m ost im p ortan t recom m en d ation th e weeks he began takin g “m edicin e to m ake m e
d octor can m ake to m od i y th is p atien t’s h ap pier.” Which o th e ollowin g m edication s
lon g-term m ortality risk is to recom m en d is th is p atien t m ost likely to be takin g?
th at sh e (A) Bu p rop ion
(A) stop sm okin g (B) Flu oxetin e
(B) start u sin g a seat belt regu larly (C) Lorazep am
(C) redu ce red m eat in h er diet (D) Sertralin e
(D) get a di eren t job (E) Am itrip tylin e
(E) stop drin kin g alcoh ol
160. A 50-year-old wh o h as ju st gon e
157. A p h ysician workin g at a large state th rough m en op au se tells h er p h ysician th at
college sees a 19-year-old stu d en t in th e an d sh e an d h er h u sban d h ave rarely b een
stu d en t h ealth service. Th e stu den t, wh o “in tim ate” in th e p ast year. Th e p h ysician’s
started college 1 m on th ago, tells th e d octor m ost ap p rop riate resp on se to th e p atien t is
th at sin ce sch ool started sh e h as been callin g (A) “Tell m e abou t you r relation sh ip with
h om e every n igh t. Sh e also n otes th at sh e you r h u sban d.”
starts cryin g as soon as h er m oth er an swers (B) “Sexu al p roblem s are n orm al a ter
th e ph on e. Sh e says th at wh ile sh e still m en op au se.”
en joys goin g ou t occasion ally with rien d s, (C) “Sexu al p roblem s are com m on a ter
sh e m isses h er am ily so m u ch th at sh e h as m en op au se.”
n ot been goin g to class an d is in dan ger (D) “A sex th erap ist can be h elp u l with th ese
o ailin g h er m id term exam s. Th ere is n o issu es.”
p reviou s h istory o em otion al p roblem s, an d (E) “Are th e sexu al p roblem s a ectin g oth er
th e stu den t den ies h avin g su icidal eelin gs. asp ects o you r relation sh ip with you r
Ph ysical exam in ation is u n rem arkable. h u sban d?”
Comprehensive Examination 337
161. Ju st p rior to a seriou s op eration , a 164. A 6-year-old ch ild sh ows cogn itive
75-year-old p atien t asks th e p h ysician n ot de cits, an d beh avior su ggestive o au tism .
to p ut h im on li e su p p ort i h e requ ires it Th e ch ild also sh ows abn orm al breath in g
du rin g or a ter th e su rgery. Th e p h ysician an d h an d -wrin gin g b eh avior. Wh ich o th e
agrees to ollow th e p atien t’s wish es an d ollowin g ch rom osom es is m ost likely to
docu m en ts th e con versation in th e p atien t’s be in volved in th e etiology o th is ch ild’s
ch art. A ter th e su rgery, th e p atien t requ ires sym p tom s?
li e sup p ort. Th e p atien t’s son p rodu ces a (A) 4
written will by th e p atien t dra ted 2 years (B) 11
p reviou sly statin g, “Do wh atever you can to (C) 12
keep m e alive.” Wh at sh ou ld th e p h ysician (D) 21
do at th is tim e? (E) X
(A) Have th e h osp ital ch ap lain cou n sel th e
son 165. Th e p aren ts o a 10-year-old boy rep ort
(B) Pu t th e p atien t on li e su p p ort as th e will th at h e o ten gh ts with h is broth er an d
states sister an d h as tried to stran gle th e am ily
(C) Do n ot p u t th e p atien t on li e su p p ort cat. His teach ers rep ort th at h e sh ows
(D) Con tact th e h osp ital eth ics com m ittee p roblem atic beh avior at sch ool an d was
(E) Get a cou rt order to p u t th e p atien t on recen tly ou n d settin g a re in th e coat
li e su p p ort closet. Th e m ost likely cau se o th is p ictu re is
(A) op p osition al d e ian t d isord er
162. A 78-year-old wom an wh ose h u sb an d (B) atten tion -de icit/ h yp eractivity disord er
d ied 2 m on th s ago tells h er p h ysician th at (C) p roblem s with h is p aren ts
som etim es sh e eels th at sh e sh ou ld h ave (D) con d u ct d isord er
d ied in stead o h im . Th e p atien t d en ies (E) adju stm en t disord er
su icidal th ou gh ts or p lan s. Sh e also rep orts
th at sh e h as gon e b ack to p layin g b rid ge 166. An obese 14-year-old boy is brou gh t to
with h er rien d s an d m akin g d in n er or th e doctor by h is m oth er an d h is 18-year-
h er am ily. O th e ollowin g, th e m ost old broth er. Th e m oth er, wh o cooks all o
ap p rop riate descrip tion o th e p atien t’s th e am ily’s m eals, wou ld like in orm ation
b eh avior at th is tim e is on h ow best to p rep are ood or th e boy. His
(A) adju stm en t disord er with d ep ression broth er, wh o exercises regu larly an d is o
(B) adju stm en t disord er with an xiety n orm al body weigh t, wan ts to coach th e boy
(C) m ajor dep ressive d isord er on p h ysical tn ess. Most ap p rop riately, th e
(D) n orm al b ereavem en t doctor sh ou ld rst talk to
(E) p ersisten t d ep ressive disorder (A) th e p atien t alon e
(B) th e m oth er alon e
163. A 29-year-old wom an wh o h as b een (C) th e m oth er an d p atien t togeth er
b rou gh t to th e em ergen cy room by a rien d (D) th e p atien t, m oth er, an d broth er
tells th e p h ysician th at sh e h as n ot slep t togeth er
in 3 d ays. Sh e says sh e is stayin g awake (E) th e broth er an d p atien t togeth er
b ecau se Jesu s an d Allah asked h er to d o a
p roject to b rin g p h ysics an d scien ce in to 167. An 18-year-old m ale p atien t wh o h as
on e en tity. Her h istory reveals th at sh e h ad a m en tal age o 2 years is en rolled in a day
an ep isod e o d ep ression at th e age o 19 care p rogram with oth er teen s wh o h ave
b u t, u n til last week, sh owed n o oth er m ood disabilities. Th e m ost likely reason th at th is
ep isod es or ab n orm al b eh avior. Th e m ost p atien t wou ld n ot h it th e oth er p atien ts in
ap p rop riate d iagn osis or th is p atien t at th is th e day care cen ter is th at h e wou ld
tim e is
(A) eel badly a terward
(A) m ajor dep ressive d isord er (B) in voke an ger in th e teach er
(B) bip olar I d isorder (C) n ot wan t to h u rt th em
(C) bip olar II disorder (D) be a raid th at th ey wou ld n ot like h im
(D) brie p sych otic disorder (E) n ot wan t th em to h it h im back
(E) sch izop h ren ia
338 BRS Behavioral Science
168. A 28-year-old wom an is red rom h igh at 4+. Th e n u rse n otes th at th e wom an
h er o ce job. As sh e leaves th e o ce a ter h as requ ested a b ed p an an d h as u rin ated
gettin g th e n ews, th e wom an slip s an d alls. n orm ally. Th e m ost likely diagn osis or th is
Th e em ergen cy m edical squ ad is called wom an at th is tim e is
wh en th e wom an rep orts th at sh e can n ot (A) h ern iation o a sp in al disc
walk. In th e em ergen cy room , m edical, (B) h em isection o th e sp in al cord
orth op ed ic an d n eu rological evalu ation s (C) a som atic sym p tom d isord er
are essen tially n orm al alth ou gh th e wom an (D) actitiou s disorder
rep orts th at sh e can n ot eel p in p ricks below (E) adju stm en t disord er
th e waist an d deep ten don ref exes are
An swers an d Exp lan ation s
1. The answer is D. In creased T4, d ecreased TSH, rap id h eart rate, trem u lou sn ess, an d an xiety
are associated with h yp erth yroid ism . I th is clin ical p ictu re resu lts rom p u rp ose u lly
takin g excessive am ou n ts o exogen ou s th yroid h orm on e (to lose weigh t in th is case), th e
con d ition is kn own as actitiou s h yp erth yroidism (see Ch ap ter 13). Hash im oto th yroid itis
is ch aracterized by excessive th yroid h orm on e cau sed by overactivity o th e th yroid glan d.
Graves d isease is d iagn osed wh en th ere are lower th an n orm al levels o th yroid h orm on e in
blood . In som atic sym p tom disord er, a p erson h as p h ysical sym p tom s, b u t, in con trast to
th e p atien t in this case, th ere is n o m edical exp lan ation . Hyp erp arath yroidism sym p tom s
in clu de atigu e, dep ression , an d gastroin testin al sym p tom s, n ot th e clin ical p ictu re seen in
th is p atien t an d n ot related to takin g excessive th yroid h orm on e.
2. The answer is C. Th is wom an is in th e stage o ch an ge kn own as p rep aration . In th is stage,
th e p atien t m akes sm all im p rovem en ts in th e u n desirable beh avior (alcoh ol drin kin g in
th is case). In th e p recon tem p lation stage, th e p erson does n ot recogn ize or is in den ial
abou t th e n eed to ch an ge th e beh avior. In th e con tem p lation stage, th e p atien t is th in kin g
abou t it b u t is am b ivalen t abou t m akin g th e n eeded ch an ge. In th e action stage, th e
p atien t m akes th e n eeded ch an ge in beh avior, an d in th e m ain ten an ce stage, th e p atien t
con tin u es th e ch an ged b eh avior. In th e relap se stage, th e p atien t eels gu ilt, an ger, an d
disap p oin tm en t at reen gagin g in th e u n wan ted beh avior.
3. The answer is A. The doctor should recom m en d that the m other say “I have a severe illn ess an d
you can ask any questions you want.” Cryin g at the potential loss o a loved one is norm al, and
telling the child not to cry is n ot help ul; telling him that she will be ine or telling him nothing
is not honest. A technical explanation such as “I have leukem ia, a disease o white blood cells
that m ultiply in a disordered m an n er” is too technical an explanation or such a young child.
4. The answer is D. Blockad e o m u scarin ic recep tors is associated with blu rred vision ,
con stip ation , u rin ary reten tion , an d dry m ou th .
5. The answer is D. Th e p atien t’s sym p tom s a ter a week o treatm en t with h alop eridol,
th at is, ever, tach ycardia, trem or, an d rigidity, in dicate th at th e p atien t h as n eu rolep tic
m align an t syn d rom e, a li e-th reaten in g side e ect o an tip sych otic m edication .
6. The answer is A. The doctor should be m ost con cern ed about su icidal plan n in g in th is
p atien t. Havin g a plan an d a m ean s to com m it suicide are o m ore im m ediate dan ger than
thin kin g about suicide (suicidal ideation ). Weight loss, di iculty sleepin g, an d lack o en ergy
are also seen in depression but are n ot as closely associated with dan ger as suicidal plan n in g.
7. The answer is D. Th is m oth er is sh owin g obsessive–com p u lsive beh avior (ch aracterized
by th e d e en se m ech an ism o “u n d oin g”) to deal with h er excessive an xiety abou t h er
dau gh ter’s sa ety b ecau se o h er own rap e as a teen ager. Usin g u n d oin g, th is m oth er seeks
to reverse or “u n do” th e dan ger to h er d au gh ter by overp rotectin g h er. Th e excessive
clean in g b eh avior also sh ows h er obsessive–com p u lsive beh avior; som eh ow, clean in g can
“u n d o” or reverse h er own rap e as a teen ager.
8. The answer is B. On th e d im en sion s o severity scale or sch izop h ren ia ( rom 0–20), th is
p atien t will h ave a score closest to 4. He wou ld score 0 (n ot p resen t) or delu sion s, 3 or
h allu cin ation s (h earin g th e voice o a n on existen t p erson ), 0 or disorgan ized sp eech (clear
sp eech ), 0 or ab n orm al p sych om otor b eh avior, an d 1 or n egative sym p tom s (ap p rop riate
bu t blu n ted acial exp ression ).
9. The answer is A. Th e con cep tion o death in a 7-year-old ch ild is th at oth ers can die bu t
th at h e can n ot die. It is n ot u n til abou t age 9 th at ch ildren begin to u n derstan d th at th ey
339
340 BRS Behavioral Science
can also d ie. Ch ild ren u n d er age 6 exp ect th at death is tem p orary an d th at p eop le wh o die
com e back to li e.
10. The answer is F. Th e m ost likely cau se o th e exacerbation o th is p atien t’s acn e is wearin g
a h elm et. Because th e exacerbation is on ly on th e oreh ead, oth er ch oices su ch as allergy
to th e am ily p et (th e ch in ch illa) or to m aterials u sed in road con stru ction are u n likely.
Her oreh ead is likely to b e covered by th e h elm et m akin g excessive su n exp osu re u n likely.
Ch ocolate con su m p tion or vegetarian diet is n ot associated with exacerbation o acn e.
11. The answer is B. A case–con trol design is best or th e stu dy o rare diseases becau se it
starts with id en ti ied cases o th e disease an d com p ares th eir exp osu re to a risk actor with
th at o p eop le wh o d o n ot h ave th e d isease (th e con trol grou p ). A case rep ort or m u ltip le
case rep orts wou ld in volve p eop le with th e d isease bu t wou ld n ot in clu de a con trol grou p.
Becau se a coh ort d esign in volves a grou p o h ealth y p eop le wh o are ollowed over tim e, it
cou ld take m an y years an d m an y su b jects be ore en ou gh p eop le develop th e rare disease
to obtain m ean in g u l data. A clin ical treatm en t trial cou ld be u se u l in determ in in g treat-
m en t ch oices or m an agin g th e d isease (i an y) b u t wou ld n ot b e h elp u l in d eterm in in g
risk actors or p rogn ostic in d icators or th e d isease.
12. The answer is B. In a n orm al distribution , th e p ercen tage o people that have systolic blood
p ressure th at is m ore th an 2 stan dard deviation s above the m ean is approxim ately 2.5%.
13. The answer is D. This wom an is n ow at the highest risk or osteoporosis, a sequela o anorexia
n ervosa. Derm atitis and osteoarthritis are n ot associated with a history o anorexia nervosa. In
biliary atresia, ducts to transport bile rom the liver to the duodenum ail to develop in a etus.
Am enorrhea usually resolves when a patient with anorexia nervosa recovers rom the illness.
14. The answer is C. Mem an tin e (Nam en da), an N-m eth yl- d -aspartate (NMDA) receptor an tago-
n ist, is ap p roved to slow deterioration in p atien ts with m oderate-to-severe Alzheim er’s
disease. While also used to treat Alzh eim er’s disease, tacrin e (Cogn ex), don epezil (Aricept),
rivastigm in e (Exelon ), an d galan tam in e (Rem in yl) are all acetylcholin esterase in hibitors.
15. The answer is C. O th e listed agen ts, th e m ost ap p rop riate on e to treat sleep ap n ea in th is
p atien t is m edroxyp rogesteron e acetate (Provera). Progesteron e raises restin g ven tilation
in p atien ts with d ecreased resp iratory drive, an d overweigh t p ostm en op au sal wom en with
sleep ap n ea su ch as th is p atien t can b en e it. Wh ile th ey m ay be u sed to treat sleep ap n ea in
som e p atien ts, tricyclic an tid ep ressan ts as well as SSRIs (e.g., lu oxetin e), are less e ective
or p atien ts su ch as th is th an h orm on e treatm en t. Ben zodiazep in es su ch as diazep am an d
alp razolam can p rom ote sleep b u t are n ot u se u l in sleep ap n ea.
16. The answer is A. Th e p h ysician’s n ext step is to ask th e p atien t abou t h is relation sh ip with
h is caretakers. Elder abu se is a real p ossibility in th is case, p articu larly sin ce th e p atien t
seem s to b e avoid in g eye con tact. Assessin g th e p atien t or a cogn itive disorder or order-
in g m easu res to p rotect th e p atien t (i n ecessary) can wait u n til th e p atien t is qu estion ed
abou t h is caretakers.
17. The answer is B. Use o cocain e is m ost likely to h ave cau sed th e seizu re in th is p atien t.
With drawal rom ben zodiazep in es su ch as alp razolam also can cau se seizu res, bu t th is
p atien t h ad alp razolam in h er system an d so is u n likely to be in with drawal. Mariju an a u se
m ariju an a with drawal, an d cocain e with drawal are n ot associated with seizu res.
18. The answer is E. As ch ild ren with ch ron ic illn esses su ch as asth m a reach th eir teen years,
th ey are less likely to adh ere to treatm en t th at sets th em ap art rom oth er teen s. Th e m ost
e ective way to in crease adh eren ce in su ch teen agers is to en cou rage in teraction with
oth er teen s wh o h ave th e sam e con dition . Frigh ten in g th e boy or recom m en din g cou n -
selin g or goin g to th e sch ool n u rse will n ot be e ective in in creasin g h is ad h eren ce. Oral
m ed ication or asth m a m ay n ot be m ed ically ap p rop riate or th is p atien t.
19. The answer is A. Th e typ e o dru g m ost likely to h ave cau sed th is p roblem is an an tidep res-
san t agen t, n am ely, a m on oam in e oxidase in h ib itor. Th ese agen ts block th e breakdown
o tyram in e (a p ressor) in th e gastroin testin al tract as well as in th e b rain , resu ltin g in
Comprehensive Examination 341
elevated b lood p ressu re, occip ital h ead ach e, an d oth er seriou s sym p tom s ollowin g in ges-
tion o tyram in e-rich oods (e.g., aged ch eese an d red win e).
20. The answer is B. Bein g divorced an d b ein g m ale are risk actors or su icide.
21. The answer is E. Becau se th eir cau se is com p letely p h ysiological, h ot lash es or lu sh es are
th e sym p tom o m en op au se m ost likely to be seen in 50-year-old wom en in all cu ltu res.
Th e “em p ty n est” syn drom e, dep ression , an xiety, an d in som n ia are m ore closely associated
with societal actors an d so are m ore likely to di er across cu ltu res.
22. The answer is E. Patien ts an d p h ysician s com m on ly p re er selective seroton in reu p take
in h ib itors (SSRIs) to tricyclic an tidep ressan ts becau se SSRIs h ave ewer side e ects an d
th u s are m ore likely to b e well-tolerated . Both grou p s o an tidep ressan ts h ave sim ilar
action on m ood an d sleep. All take 3–4 weeks to work an d n eith er grou p is e ective or low-
erin g b lood p ressu re.
23. The answer is F. Th is treatm en t tech n iqu e in wh ich a p h obic p atien t is tau gh t relaxation
tech n iqu es an d is th en exp osed to in creased “doses” o th e eared ob ject is b est d escribed
as system atic desen sitization .
24. The answer is B. Becau se it is likely to cau se th e least exertion or th e p atien t, th e p h y-
sician’s best recom m en dation is ace to ace, em ale su p erior (wom an on th e top ). To
en h an ce th e p atien t’s recovery, th e cou p le sh ou ld be en cou raged to retu rn to th eir n orm al
activities (in clu din g sex) as soon as it is sa e to do so. Avoidin g sexu al activity or a p ro-
lon ged p eriod o tim e can delay th e p atien t’s recovery.
25. The answer is C. Poor physical care, bruises, and abrasions in this dem ented elderly patient
in dicate that he has been n eglected and abused. Even though he denies that anyone has
harm ed him , the m ost likely abuser is his daughter. There ore, the m ost appropriate action or
the physician to take a ter treatin g this patient is to contact the appropriate state social service
agen cy. As in cases o child abuse, speakin g to the likely abuser about the physician’s concerns
is n ot n ecessary. The physician also can n ot send the patient hom e with the likely abuser or
with an other relative. The social service agency will deal with the patient’s ultim ate placem ent.
I n ecessary, a neurologic evaluation can be done at a later date (and see Question 16).
26. The answer is A. Hisp an ic Am erican s h ave lon ger li e exp ectan cies th an A rican
Am erican s, Wh ite Am erican s, or Native Am erican s.
27. The answer is B. Wh ile som e Am erican s m ay u n derstan d th at it is th erap eu tic to discu ss
you r in tern al em otion al p rob lem s with oth ers or th at u n con sciou s con licts can be m an i-
ested as p h ysical illn ess, a sign i ican t n u m ber o Am erican s believe th at m en tal illn ess is a
sign o p erson al weakn ess or ailu re. Man y also believe th at m en tally ill p eop le h ave p oor
sel -con trol. For th ese an d oth er reason s, m an y m en tally ill p eop le do n ot seek h elp.
28. The answer is C. In p erson s with d elu sion al disorder, delu sion s (in th e p ersecu tory typ e,
th e belie th at on e’s n eigh bors are en terin g on e’s h om e at n igh t) are p resen t with ou t
abn orm al th ou gh t p rocesses. Ab sen ce o m ood sym p tom s m akes th e diagn osis o b ip olar
disord er an d sch izoa ective d isord er u n likely. Social with drawal, bu t n o ran k delu sion s,
ch aracterizes sch izoid p erson ality d isorder (see also an swers to Qu estion 29).
29. The answer is C. Th is wom an wh o b elieves th at sh e is p regn an t with th e ch ild o a celeb -
rity p rob ab ly also h as d elu sion al d isord er, in th is case th e erotom an ic typ e (an d see
Qu estion 28).
30. The answer is A. Pregn an cy an d ch ild birth are m ore likely to cau se death in th is 40-year-
old wom an th an an y con tracep tive tech n iqu e.
31. The answer is C. Th e colleagu e’s best resp on se is “Reassu re p atien ts th at th e skin con di-
tion you h ave is n ot con tagiou s.” It is better to ace th e p roblem th an to act like n oth in g is
wron g or to p u t p atien ts o by tellin g th em it is n ot th eir p roblem . Th e p h ysician sh ou ld be
en cou raged to see p atien ts an d d eal with th e p roblem op en ly rath er th an to avoid qu es-
tion s by wearin g lon g-sleeved sh irts or ign orin g th e issu e.
342 BRS Behavioral Science
32. The answer is B. Th e u su al stan dards o doctor–patien t con iden tiality app ly to the recen tly
bereaved wom an wh o h as n ot exp ressed a p lan an d is curren tly n ot at high risk to kill
h ersel . In con trast, th e dep ressed wom an wh o tells her physician that she has saved up 50
barbiturate tablets (has a suicidal plan ) an d wan ts to die is at high risk to kill hersel . Other
excep tion s to con iden tiality in clu de p atien ts who com m it child abuse, put their sexual
p artn ers at risk or HIV in ection , or in dicate th at they plan to harm som eon e.
33. The answer is C. Th e m ost ap p rop riate action or Doctor A to take is to rep ort Doctor B
to h is su p erior at th e h osp ital. Rep ortin g o a lap se by a colleagu e is requ ired eth ically
becau se p atien ts m u st be p rotected. Talkin g to Doctor B ab ou t h is lap se again , warn in g
h im , rep ortin g to th e p olice, or recom m en din g a tran s er is n ot likely to accom p lish th e
im m ediate goal o p rotectin g p atien ts.
34. The answer is G. The Folstein Min i–Men tal State Exam in ation is used to ollow im prove-
m en t or deterioration in patien ts with suspected n eurologic dys un ction . Positron em is-
sion tom ography (PET) localizes physiologically active brain areas by m easurin g glucose
m etabolism . Com puted tom ography (CT) iden ti ies organ ically based brain chan ges, such as
en larged ven tricles. Th e them atic app erception test (TAT) utilizes drawin gs depictin g am big-
u ous social situation s to evaluate u n con scious con licts. The sodium am obarbital (Am ytal)
in terview is used to determ in e whether p sych ological actors are respon sible or behavioral
sym p tom s. The electroen cephalogram (EEG), which m easures electrical activity in the cor-
tex, is use ul in diagn osin g epilepsy an d in di eren tiatin g deliriu m rom dem en tia. The Wide
Ran ge Achievem en t Test (WRAT) is used clin ically to evalu ate readin g, arithm etic, an d other
school-related skills in patien ts. The Glasgow Com a Scale quan ti ies level o con sciousn ess
on a scale o 3 to 15.
35. The answer is D. The them atic apperception test (TAT) utilizes drawings depicting am biguous
social situations to evaluate unconscious con licts in patients (see answer to Question 34).
36. The answer is B. Typ ically, in an ts begin to roll over rom back to belly an d belly to back at
abou t 5 m on th s o age.
37. The answer is B. Legal in toxication is d e in ed by blood alcoh ol con cen tration s o 0.05%–
0.15%, dep en din g on in dividu al state law.
38. The answer is G. Protrip tylin e is less sed atin g th an doxep in , n ortrip tylin e, am itrip tylin e,
an d im ip ram in e an d th u s is th e m ost ap p rop riate h eterocyclic an tidep ressan t or som eon e
wh o m u st stay alert on th e job. Wh ile lu oxetin e is also u n likely to be sedatin g, it is a selec-
tive seroton in reu p take in h ib itor (SSRI), n ot a h eterocyclic agen t. Selegilin e an d tran ylcy-
p rom in e are m on oam in e oxidase in h ibitors.
39. The answer is F. This elderly wom an who reports that she has di iculty sleepin g through the
night because o m uscular contractions in her legs is showing evidence o nocturnal m yoclonus.
40. The answer is E. In tellectu alization , u sin g th e m in d’s h igh er u n ction s to avoid exp erien c-
in g an xiety associated with th e likelih ood o crash in g, is th e de en se m ech an ism bein g
u sed by th is p ilot.
41. The answer is D. Typically, children begin to walk unassisted between 12 and 15 m onths o age.
42. The answer is B. Th e treatm en t tech n iqu e d escrib ed h ere is bio eed back. In th is treatm en t,
th e p atien t is given on goin g p h ysiologic in orm ation abou t th e ten sion in th e ron talis
m u scle an d learn s to u se m en tal tech n iqu es to con trol th is ten sion .
43. The answer is D. Th is p atien t wh o h as a u ll n igh t’s sleep bu t does n ot eel u lly awake u n til
h ou rs a ter h e irst wakes u p is sh owin g eviden ce o a sleep disorder kn own as sleep dru n k-
en n ess. Th is con d ition is rare, an d th e diagn osis can on ly b e m ad e in th e ab sen ce o oth er
m ore com m on p rob lem s d u rin g sleep (e.g., sleep ap n ea) or su bstan ce u se.
44. The answer is C. Tach ycard ia (in creased h eart rate) is seen with th e u se o all o th e stim u -
lan t dru gs, in cludin g ca ein e. Stim u lan t dru gs also ten d to in crease en ergy, blood p res-
su re, an d gastric acid secretion an d im p rove m ood.
Comprehensive Examination 343
45. The answer is A. Th e social sm ile com m on ly irst ap p ears at ab ou t 2 m on th s o age in typ i-
cal in an ts.
46. The answer is F. Th e Wid e Ran ge Ach ievem en t Test (WRAT) is clin ically u sed to evalu ate
readin g, arith m etic, an d oth er sch ool-related skills in p atien ts (see also An swer 34).
47. The answer is C. Slow waves are ch aracteristic o delta sleep (stages 3 an d 4).
48. The answer is A. In an ts can visu ally track a h u m an ace an d objects startin g at birth .
49. The answer is E. Like th e p ilot in Qu estion 40, th is p h ysician , wh o h as been given a diag-
n osis o term in al p an creatic can cer, is u sin g th e de en se m ech an ism o in tellectu alization
(i.e., h e is u sin g h is in tellect an d kn owled ge to avoid exp erien cin g th e righ ten in g em otion s
associated with h is illn ess) (an d see Qu estion 40).
50. The answer is A. By actin g ou t, th e teen ager’s u n accep table an xiou s an d dep ressed eelin gs
are exp ressed in action s (stealin g a car).
51. The answer is C. By u sin g den ial, th is wom an re u ses to believe wh at to h er is th e in toler-
able act th at she h as breast can cer.
52. The answer is F. Th is p atien t is u sin g th e d e en se m ech an ism o reaction orm ation , wh ich
in volves adop tin g b eh avior (i.e., com p lim en tin g th e p h ysician ) th at is th e op p osite o th e
way sh e really eels (i.e., an ger toward th e p h ysician ).
53. The answer is G. Th is wom an is sh owin g eviden ce o th e avoidan t p erson ality disorder.
Becau se sh e is overly sen sitive to rejection , sh e h as becom e socially with drawn . In con trast
to th e sch izoid p atien t wh o p re ers to be alon e, th is p atien t is in terested in m eetin g p eop le
bu t is u n able to d o so becau se o h er sh yn ess, eelin gs o in eriority, an d tim id ity.
54. The answer is H. Th is beh avior is m ost closely associated with th e h istrion ic p erson ality
disord er. Person s with th is disord er are dram atic wh en rep ortin g th eir sym p tom s to p h ysi-
cian s an d call atten tion to th em selves with th eir dress an d beh avior.
55. The answer is D. In ten se h u n ger, tiredn ess, an d h eadach e are all sign s o with drawal rom
am p h etam in es.
56. The answer is B. Th e h istory o in som n ia in dicates th at th is p atien t m ay h ave been given
a p rescrip tion or a b arb itu rate su ch as secob arb ital (Secon al). His h istory o dep ression
u rth er su ggests th at h e h as taken an overdose o th e dru g in a su icide attem p t.
57. The answer is C. Use o b oth p h en cyclid in e (PCP) an d lysergic acid dieth ylam ide (LSD)
resu lts in eelin gs o altered b ody state su ch as th is p atien t describes. However, in con trast
to LSD, in creased aggressivity an d n ystagm u s (i.e., abn orm al h orizon tal or vertical eye
m ovem en ts) are m ore likely to b e seen with PCP u se.
58. The answer is C. With drawal rom ca ein e an d oth er stim u lan t d ru gs is associated with
h eadach e, leth argy, dep ression , an d in creased ap p etite. Pu p il dilation is associated with
th e u se o , rath er th an with drawal rom , stim u lan ts.
59. The answer is H. Th e Glasgow Com a Scale (scores ran ge rom 3 to 15) is u sed to evalu ate
th e level o con sciou sn ess in p atien ts (see also an swer to Qu estion 34).
60. The answer is B. Alp h a waves are associated with th e awake relaxed state with eyes closed.
61. The answer is B. Th is wom an h as sym p tom s o gen itop elvic p ain / p en etration disord er
(i.e., p h ysically u n exp lain ed p ain with sexu al in tercou rse).
62. The answer is B. With in th e irst ew m on th s o an im p orta n t loss, p eop le o ten resp on d
in ten sely. Th ey m ay even h a ve th e illu sion th at th ey see th e d ea d p erson . Th e p h ysi-
cian sh ou ld p rovid e su p p ort an d reassu ran ce sin ce th is p atien t p rob a b ly is exp erien c-
in g a n orm a l grie reaction . Wh ile lim ited u se o m ed ica tion s or sleep is ap p rop riate,
an tip sych otic or a n tid ep ressa n t m ed ica tion s are n ot in d ica ted in th e m an agem en t o
n orm a l grie .
344 BRS Behavioral Science
63. The answer is C. Th e m on ozygotic twin o a p erson with sch izop h ren ia h as abou t a 50%
ch an ce o develop in g th e disorder. Th e ch ild o on e p aren t with sch izop h ren ia or th e dizy-
gotic twin o a patien t with sch izop h ren ia h as abou t a 10% ch an ce, an d th e ch ild o two
p aren ts with sch izop h ren ia h as abou t a 40% ch an ce. En viron m en tal even ts su ch as bein g
raised in an in stitu tion al settin g are n ot risk actors or th e develop m en t o sch izop h ren ia.
64. The answer is E. Feelin g th at on e is p erson ally resp on sible or a m ajor disaster wh en on e
h ad n oth in g to do with it is a delu sion in th is dep ressed 49-year-old m an . His oth er state-
m en ts, wh ile in dicatin g eelin gs o in ad equ acy an d h op elessn ess, are com m on ly seen in
dep ression b u t do n ot in dicate p sych otic th in kin g.
65. The answer is B. Paren ts can n ot re u se li esavin g treatm en t or th eir ch ild or an y reason .
Becau se th ere is n o tim e b e ore th e ch ild m u st h ave th e tran s u sion , treatm en t can p ro-
ceed on an em ergen cy b asis. Th ere is n o reason to th reaten th e p aren ts with legal action .
66. The answer is D. Th is p atien t sh ows evid en ce o con version disorder. Th is disorder
in volves n eu rological sym p tom s with n o p h ysical cau se, typ ically occu rrin g a ter a stress-
u l li e even t. Sen sory loss in p atien ts with con version disorder ap p ears su dden ly. Patien ts
with th is d isord er are m ore likely to b e you n g an d em ale. Th ey requ en tly sh ow “la belle
in di éren ce,” an u n exp ected lack o con cern abou t th e dram atic sym p tom .
67. The answer is C. In th e Un ited States, lon g-term p sych iatric h osp itals are own ed an d op er-
ated p rim arily by state govern m en ts.
68. The answer is B. Patien ts with dissociative ugue, a dissociative disorder, wan der away rom
their h om es an d do n ot kn ow how th ey got to an other destin ation . This m em ory loss an d
wan derin g o ten occur ollowin g a stress ul li e even t, in this case the patien t’s loss o his job.
69. The answer is E. Hu n tin gton’s disease com m on ly irst ap p ears between th e ages o 35
an d 45 years. Lesch -Nyh an syn d rom e an d Rett’s disorder are ap p aren t du rin g ch ildh ood;
sch izop h ren ia u su ally ap p ears in ad olescen ce or early ad u lth ood ; Alzh eim er’s d isease m ost
com m on ly ap p ears in old age.
70. The answer is E. Retin al p igm en tation is p rim arily associated with u se o th e low-p oten cy
an tip sych otic agen t th iorid azin e.
71. The answer is E. Delta waves are seen in n on -REM sleep stages 3 an d 4. Pen ile an d clitoral
erection , in creased p u lse, in creased resp iration , elevated b lood p ressu re, dream in g, an d
aton y o skeletal m u scles are all seen in REM sleep.
72. The answer is B. O th e d isord ers listed, th e largest sex di eren ce in th e occu rren ce o a
disord er is seen in m ajor d ep ressive disorder. Two tim es m ore wom en th an m en are diag-
n osed with th is disorder. Th ere is n o sign i ican t sex di eren ce in th e occu rren ce o sch izo-
p h ren ia, cycloth ym ic disord er, illn ess an xiety disorder, or bip olar disorder.
73. The answer is A. Negative p redictive valu e is th e p robability th at a p erson with a n egative
screen in g test is actu ally well.
74. The answer is A. Risin g o th e u teru s in th e p elvic cavity with sexu al activity (i.e., “th e ten t-
in g e ect”) irst occu rs d u rin g th e excitem en t p h ase o th e sexu al resp on se cycle.
75. The answer is B. Th e sexu al p artn er, or exam p le, th e wi e, ap p lies th e squ eeze in th e
squ eeze tech n iqu e, a m eth od u sed to d elay ejacu lation in m en wh o ejacu late p rem atu rely.
In th is tech n iqu e, th e m an iden ti ies a p oin t at wh ich ejacu lation can still be p reven ted. He
th en in stru cts h is p artn er to ap p ly gen tle p ressu re to th e coron a o th e p en is. Th e erection
th en su bsid es an d ejacu lation is d elayed .
76. The answer is C. An alysis o varian ce is u sed to exam in e di eren ces am on g m ean s o m ore
th an two sam p les or grou p s. In th is exam p le, th ere are th ree sam p les (i.e., age grou p s).
77. The answer is B. This m an h as acquired erectile dys u n ction , problem s with erection occur-
rin g a ter a period o n orm al un ction in g. Alcohol use is com m on ly associated with this
con dition .
Comprehensive Examination 345
78. The answer is A. Th e od d s–risk ratio (od ds ratio) o 2 in th is case–con trol stu dy is calcu -
lated as ollows:
79. The answer is E. In a coh ort stu dy, th e ratio o th e in ciden ce rate o a con dition (e.g., m is-
carriage) in exp osed p eop le to th e in ciden ce rate in u n exp osed p eop le is th e relative risk.
80. The answer is B. 81. The answer is E. The attributable risk is the inciden ce rate in exposed peo-
ple (5.0/ 1000) m in us the in ciden ce rate in un exposed people (0.5/ 1000) = 4.5. There ore, 4.5 is
the addition al risk o gettin g TB associated with livin g with som eon e with TB. The relative risk
is the in ciden ce rate in exposed people (5.0/ 1000) divided by the in ciden ce rate in unexposed
people (0.5/ 1000) = 10.0. There ore, the chances o gettin g TB are 10 tim es greater when livin g
with som eon e who has TB than when livin g in a household in which n o on e has TB.
82. The answer is B. The odds–risk ratio is used to estim ate the relative risk in a case–control study.
83. The answer is B. Th is p atien t is m ost likely to h ave m ajor dep ressive disorder. Eviden ce
or th is is m issin g work, eelin g h op eless an d tired, losin g >5% o body weigh t, an d h avin g
trou ble sleep in g. Su icidal ideation is sh own by h er re eren ce to death (i.e., “Doctor, th e
Lord calls all h is ch ildren h om e”).
84. The answer is E. As it is on ly 2 weeks sin ce the traum atic even t occurred, this patien t is
m ost likely to h ave acu te stress disorder. Posttrau m atic stress disorder (PTSD) can n ot be
diagn osed un til at least 1 m on th has passed a ter the traum atic even t. Obsessive–com pul-
sive disorder (OCD) is a disorder ch aracterized by obsession s an d com pulsion s, an d pan ic
disorder is ch aracterized by su dden attacks o in ten se an xiety an d a eelin g that on e is about
to die. In OCD, gen eralized an xiety disorder, an d pan ic disorder, there is n o obvious precipi-
tatin g even t.
85. The answer is A. A ter a li e-th reaten in g even t, h yp ervigilan ce (e.g., ju m p in g at every lou d
n oise), lash b acks (re-exp erien cin g o th e even t), an d p ersisten t an xiety su ggest PTSD.
Acu te stress disorder can on ly be d iagn osed with in 1 m on th o th e trau m atic even t (see
also an swer 84).
86. The answer is C. Usin g recap itu lation , th e in terviewer su m s u p all o th e in orm ation given
by th e p atien t to en su re th at it h as been correctly d ocu m en ted.
87. The answer is B. “Man y p eop le eel th e way you do wh en th ey irst n eed h osp italization” is
an exam p le o th e in terview tech n iqu e kn own as validation . In validation , th e in terviewer
gives creden ce to th e p atien t’s eelin gs an d ears.
88. The answer is E. “You say th at you elt th e p ain m ore in th e even in g?” is an exam p le o th e
in terview tech n iqu e kn own as re lection .
89. The answer is A. Com m en tin g on bod y lan gu age in dicatin g an xiety an d n otin g in con -
sisten cies b etween verb al resp on ses an d body lan gu age dem on strate th e in terviewin g
tech n iqu e kn own as con ron tation .
90. The answer is D. Sudden ly eelin g anxious, becom ing dizzy, and eeling like one cannot breathe
when exposed to an open area are m an i estations o a panic attack with agoraphobia.
91. The answer is C. In an illu sion , an in d ivid u al m isp erceives a real extern al stim u lu s. In th is
case, th e in dividu al h as seen som eon e b u t h as in terp reted th e p erson as bein g h er ath er.
Illu sion s are n ot u n com m on in a n orm al grie reaction .
92. The answer is F. Positron em ission tom ograp h y (PET) scan s can localize m etabolically
active b rain areas in p erson s wh o are p er orm in g sp eci ic tasks.
346 BRS Behavioral Science
93. The answer is C. Au d itory evoked p oten tials, th e resp on ses o th e brain to sou n d as m ea-
su red by electrical activity, are u sed to evalu ate loss o h earin g in in an ts.
94. The answer is C. In m alin gerin g, th e p atien t p reten ds th at sh e is ill in order to realize an
obviou s (e.g., in an cial) gain .
95. The answer is B. In actitiou s disorder im p osed on sel , th e p atien t sim u lates illn ess or
m ed ical atten tion . Th e gain to th is p atien t, i.e., atten tion rom oth ers or b ein g ill, is n ot
obviou s as it is in th e m alin gerin g p atien t (see also an swer to Qu estion 94).
96. The answer is C. Early m orn in g awaken in g is a typ e o in som n ia th at is com m on ly seen in
p eop le with m ajor d ep ressive d isorder.
97. The answer is D. Patien ts with ob stru ctive sleep ap n ea are requ en tly u n aware th at th ey
h ave awaken ed o ten d u rin g th e n igh t b ecau se th ey can n ot breath e. Th ey sn ore lou dly
an d o ten b ecom e ch ron ically tired .
98. The answer is C. Con version disord er in volves a dram atic loss o m otor or sen sory u n c-
tion with n o m edical cau se. Th ere is o ten a cu riou s lack o con cern (“la belle in di -
éren ce”) abou t th e sym p tom s. Illn ess an xiety disorder is an exaggerated con cern with
illn ess or n orm al bodily u n ction s. Peop le with body dysm orp h ic disorder eel th at th ere
is som eth in g seriou sly wron g with th eir ap p earan ce. In som atic sym p tom disorder,
p atien ts h ave p h ysical sym p tom s, o ten over m an y years, th at h ave n o biological cau se.
Gen eralized an xiety disorder is ch aracterized by ch ron ic (at least 6 m on th s o ) an xiety.
99. The answer is A. Th is p atien t is sh owin g evid en ce o illn ess an xiety disord er, an exagger-
ated con cern with illn ess.
100. The answer is A. In op eran t con d ition in g, a n on re lexive beh avior, su ch as a dog tu rn in g a
doorkn ob, is learn ed by u sin g rein orcem en t, su ch as a treat.
101. The answer is G. In th is exam p le o n egative rein orcem en t, a p atien t in creases h is beh av-
ior (e.g., goin g to p h ysical th erapy session s) in order to redu ce an aversive stim u lu s (e.g.,
h is sh ou lder p ain ).
102. The answer is D. Th is wom an is m ost likely to h ave deliriu m cau sed by th e h igh ever.
103. The answer is B. Facial tics, cu rsin g, an d grim acin g seen in th is you n g m an are sym p tom s
o Tou rette’s d isord er.
104. The answer is C. Th is p atien t is m ost likely to h ave Alzh eim er’s d isease. Becau se h er
level o atten tion is n orm al, th is is n ot d eliriu m . Th ere is n o evid en ce o d ep ression
(p seu d od em en tia), an d th is p atien t h as n o h istory o alcoh ol u se to su ggest su b stan ce/
m ed ication in d u ced m ajor n eu rocogn itive d isord er.
105. The answer is C. Th is statem en t is an exam p le o th e Kü bler-Ross stage o dyin g kn own as
bargain in g.
106. The answer is B. In aversive con d ition in g, an u n wan ted beh avior (n ail bitin g) is p aired
with an u n p leasan t stim u lu s (n oxiou s-tastin g su bstan ce) an d th e beh avior ceases.
107. The answer is D. Becau se it is less likely th an th e ben zodiazep in es (e.g., diazep am ) to
cau se dep en d en ce, th e b est ch oice o m edication or th is p atien t with gen eralized an xiety
disord er (i.e., ch ron ic an xiety) is bu sp iron e. Lith iu m is u sed to treat b ip olar d isord er, an d
wh ile it can be h elp u l, am itrip tylin e h as sign i ican t side e ects an d th u s is n ot likely to be
u sed or th is p atien t.
108. The answer is A. Head Start an d ed u cation al p rogram s like it are exam p les o p rim ary
p reven tion , m ech an ism s to red u ce th e in cid en ce o a p roblem (e.g., sch ool ailu re) by
redu cin g its associated risk actors (e.g., lack o edu cation al en rich m en t).
109. The answer is A. Rep ression , th e d e en se m ech an ism in u se wh en u n accep table em otion s
are p reven ted rom reach in g awaren ess, is th e de en se m ech an ism on wh ich all oth ers are
based .
Comprehensive Examination 347
110. The answer is E. Most ap p rop riately, th e p h ysician sh ou ld tell th e p atien t th at sh e can
take h er tim e an d n ot try to sp eak wh ile sh e is cryin g.
111. The answer is D. Th e p aren t’s con cern s are real. Th ere ore, to take n o u rth er action is n ot
an accep tab le ch oice or th e p h ysician . Th e p h ysician’s m ost ap p rop riate recom m en d a-
tion is to recom m en d a lon g-actin g con tracep tive or th is you n g wom an . Perm an en t
orm s o birth con trol, su ch as tu bal ligation or oop h orectom y, are n ot ap p rop riate.
Preven tin g h er rom goin g to th e sch ool or ear o p regn an cy cou ld lim it th e social, aca-
dem ic, an d em p loym en t p oten tial o th is you n g wom an .
112. The answer is B. Usin g th e in telligen ce qu otien t (IQ) orm u la (i.e., m en tal age [MA]/
ch ron ological age [CA] × 100 = IQ), th e MA o th is ch ild is 3 years (MA/ 6 × 100 = 50). Like a
typ ical 3-year-old ch ild , som eon e with a m en tal age o 3 years can iden ti y colors bu t can -
n ot read , copy a trian gle, ride a two-wh eeled bicycle, or u n derstan d th e m oral di eren ce
between righ t an d wron g.
113. The answer is D. Prior to treatin g th e 16-year-old p atien t, th e p h ysician sh ou ld recom -
m en d th at h e tell h is sexu al p artn er(s). Th ere is n o n eed to break doctor–p atien t con i-
den tiality by tellin g th e sexu al p artn er(s) sin ce th e illn ess is n ot li e-th reaten in g. Paren ts
do n ot h ave to be told or give p erm ission to treat sexu ally tran sm itted diseases in teen ag-
ers. Gen ital h erp es is n ot gen erally rep ortab le to state or ed eral h ealth au th orities.
114. The answer is E. With resp ect to p h ysical, social, an d cogn itive/ verbal develop m en t,
resp ectively, th is 9-m on th -old ch ild is best described as typ ical, typ ical, typ ical. Ch ildren
can sit u n assisted an d p u ll th em selves u p to stan d by abou t age 10 m on th s. At abou t age
7 m on th s, ch ildren begin to sh ow stran ger an xiety (th e babysitter is essen tially a stran ger
becau se th e ch ild sees h er on ly on ce a week). Ch ild ren com m on ly d o n ot sp eak u sin g
u n d erstan d ab le word s u n til th ey are ab ou t 1 year old.
115. The answer is E. Th is ch ild’s m otor skills (e.g., walkin g u p stairs 1 oot at a tim e, scrib -
blin g wh en told to copy a circle) an d social skills (e.g., m ovin g away rom an d th en toward
h is m oth er) in d icate th at th is ch ild is abou t 1½ years old. With resp ect to verbal skills,
ch ildren o th is age are ab le to u se abou t 10 in dividu al words. Ch ildren 3 years o age u se
abou t 900 word s, u n d erstan d ab ou t 3,500 words, an d sp eak in com p lete sen ten ces. At
abou t 4 years o age, ch ild ren u se p rep osition s (e.g., below, u n der) in sp eech .
116. The answer is B. A statem en t su ch as “I h ave a gu n in m y h ou se” m ade to a p h ysician is
a warn in g sign su ggestin g th at th is p atien t is p lan n in g to h arm h im sel or som eon e else.
Th ere ore, th e m ost ap p rop riate action or th e p h ysician to take at th is tim e is to su ggest
th at th e p atien t rem ain in th e h osp ital or u rth er evalu ation . I th e p atien t re u ses, h e
can b e h eld again st h is will or a lim ited p eriod o tim e. In orm in g th e wi e o th e th reat,
rem ovin g th e gu n , an d avoid in g dan gerou s m edication s are u se u l strategies bu t will n ot
p reven t th e d an gerou s act rom occu rrin g.
117. The answer is D. Th e m ech an ism th at is likely to u n d erlie th is m an’s p reoccu p ation with
bon d trad in g is th at h e m akes m on ey on a variable ratio rein orcem en t sch edu le. Sin ce
h e n ever kn ows h ow m an y trad es h e h as to m ake to get rein orcem en t (i.e., m on ey), h is
p reoccu p ation p ersists (i.e., is resistan t to extin ction ) on weeken ds even th ou gh h e can -
n ot receive rein orcem en t b ecau se th e m arkets are closed.
118. The answer is B. Most typ ical 3-year-old ch ildren can ride a tricycle, sp eak in com p lete
sen ten ces, an d p lay in p arallel with (n ext to) oth er ch ild ren . Th ey gen erally d o n ot p lay
coop eratively with oth er ch ildren u n til abou t 4 years o age. Th u s, th is ch ild m ay n eed
evalu ation in m otor skills (e.g., h e sh ou ld be able to p edal a tricycle) bu t is typ ical in lan -
gu age an d social skills.
119. The answer is C. Th e p h ysician sh ou ld reassu re th is 14-year-old boy th at m astu rbation
is n orm al. An y am ou n t o m astu rb ation is n orm al, p rovided it does n ot p reven t a p erson
rom h avin g an active, su ccess u l li e. Th ere is n o dys u n ction in th is boy, an d it is n ot
ap p rop riate to n oti y h is p aren ts, re er h im to a p sych ologist, m easu re h is testosteron e
level, or tell h im to b ecom e in volved in sch ool sp orts.
348 BRS Behavioral Science
120. The answer is B. On e year a ter th e last m en stru al p eriod u su ally sign als th e en d o m en o-
p au se, an d th e use o birth con trol can be discon tin u ed. Th e age o m en op au se an d th e
occu rren ce o h ot lash es vary con sid erably am on g wom en an d th u s can n ot be u sed to
p redict th e en d o ertility.
121. The answer is B. Help in g oth er ch ild ren to ad ju st to th e h osp ital is an exam p le o th is
8-year-old girl’s u se o th e de en se m ech an ism o su blim ation . In su blim ation , th e ch ild
rerou tes h er own u n con sciou s, an xiou s eelin gs abou t h er h osp italization in to socially
accep tab le b eh avior (e.g., h elp in g oth er righ ten ed ch ildren ).
122. The answer is H. Because Medicare coverage lasts or li e an d because she has the lon gest
li e expectan cy, a White em ale n on sm oker is likely to use m ore Medicare services an d un ds
than a Wh ite m an , A rican Am erican wom en an d m en , an d sm okers du rin g her li etim e.
123. The answer is D. Th is ch ild is m ost likely to b e 36 m on th s o age. At age 3 years, ch ildren
can u se abou t 900 words an d stack n in e b locks. Th ey are also ab le to sp en d a ew h ou rs
away rom th eir p rim ary caregiver each d ay.
124. The answer is B. Th e m ost likely reason or a p hysician to be sued or m alpractice is that
the ph ysician had p oor rapp ort with a p atien t. Th e doctor–p atien t relation ship is th e m ost
im portan t actor in whether or n ot a patien t will sue a physician . The physician’s m edical or
su rgical skills have less to do with whether or n ot the physician will be sued by a patien t.
125. The answer is E. Th e m ost ap p rop riate action or th e p h ysician is to ollow th e wish es o
th e n eigh bor. In th is exam p le, th e n eigh bor can decide wh eth er or n ot to con tin u e li e
su p p ort sin ce sh e h as assu m ed th e p ower to sp eak or th e p atien t by virtu e o th e docu -
m en t givin g h er d u rab le p ower o attorn ey.
126. The answer is C. Most eld erly Am erican s sp en d th e last 5 years o th eir lives livin g on th eir
own in th eir own resid en ces. Sm aller n u m b ers o elderly Am erican s en d u p in n u rsin g
h om es or livin g with am ily m em bers. Hosp ice care is aim ed at p eop le exp ected to die
with in 6 m on th s. Hosp ital stays cu rren tly average less th an 1 week.
127. The answer is B. Th e m ost e ective in terven tion or th is 85-year-old p atien t with
Alzh eim er’s d isease, wh o wan d ers ou t o th e h ou se, is to label all th e doors. Sh e m ay
wan der ou t becau se sh e n o lon ger kn ows wh ere each door leads. Medication s can be
h elp u l or associated sym p tom s (e.g., diazep am or an xiety) an d to delay u rth er declin e
(e.g., don ep ezil, an acetylch olin esterase in h ib itor), bu t can n ot rep lace lost u n ction .
Nu rsin g h om e p lacem en t sh ou ld b e con sidered i th e caregiver wish es it. Lon g-term u se
o restrain ts is n ever ap p rop riate.
128. The answer is D. Sin ce th is ch ild’s p rob lem is with au th ority igu res like h is p aren ts an d
teach ers, th e b est d escrip tion or h is b eh avior is op p osition al de ian t disorder. He reads
an d com m u n icates well, an d th ere is n o evid en ce o atten tion d e icit h yp eractivity dis-
order (ADHD) or au tism sp ectru m d isord er. Becau se th is ch ild relates well to th e oth er
ch ildren in sch ool, h e is u n likely to h ave con d u ct d isord er.
129. The answer is E. Catap lexy, h yp n agogic h allu cin ation s, an d a very sh ort rap id eye m ove-
m en t (REM) laten cy in d icate th at th is p atien t h as n arcolep sy. Am p h etam in es are m ore
likely th an b en zodiazep in es, b arb itu rates, an tip sych otics, or op ioids to be u sed in th e
m an agem en t o n arcolep sy.
130. The answer is B. Th e p h ysician’s m ost ap p rop riate action is to h ave th is p atien t call h im
over th e n ext ew weeks to rep ort h ow sh e is eelin g. Th is wom an h as th e “baby blu es”
(i.e., sad n ess or n o obviou s reason a ter a n orm al delivery). Th ere is n o sp eci ic treatm en t
or baby blu es, an d th e sym p tom s u su ally disap p ear with in 2 weeks. However, becau se
som e wom en with th e b aby blu es go on to d evelop a m ajor dep ressive ep isode requ irin g
treatm en t, th e ph ysician sh ou ld sp eak to th is p atien t daily u n til h er sym p tom s rem it.
131. The answer is A. Fewer tran sp lan ts are d on e th an are n eeded p rim arily becau se th ere are
n ot en ou gh p eop le willin g to don ate th eir organ s at death .
Comprehensive Examination 349
132. The answer is A. Th is you n g wom an is m ost likely to h ave bu lim ia n ervosa, an eatin g dis-
order ch aracterized by bin ge eatin g an d p u rgin g, bu t n orm al bod y weigh t. Parotid glan d
en largem en t an d ab scesses an d d en tal caries are seen in bu lim ia as a resu lt o th e orced
vom itin g.
133. The answer is C. Th e best tim e to tell a ch ild sh e is adop ted is as soon as p ossible, u su ally
wh en th e ch ild can irst u n derstan d lan gu age. Waitin g an y lon ger th an th is will in crease
th e p robability th at som eon e else will tell th e ch ild be ore th e p aren ts are able to.
134. The answer is D. Rep ortin g o an im p aired colleague is requ ired eth ically because p atien ts
m u st be p rotected. I , as in th is case, th e colleagu e is a licen sed p h ysician , it is ap p rop riate
to n oti y th e state im p aired p h ysician s’ p rogram . I th e in tern ist talks to th e su rgeon abou t
h er con cern s, there is n o gu aran tee th at th e su rgeon will listen an d th at th e p atien ts will
b e p rotected. Rep ortin g th e su rgeon to th e p olice is n ot ap p rop riate (an d see Ch ap ter 23).
135. The answer is C. Degen eration o ch olin ergic n eu ron s in th e h ip p ocam p u s in dicates th at
th is m an is m ost likely to h ave h ad Alzh eim er’s disease. Man ia, dep ression , an xiety, an d
sch izop h ren ia are n ot sp eci ically associated with d egen eration o ch olin ergic n eu ron s.
136. The answer is C. Tear u ln ess an d overem otion ality are typical postpartum reaction s, that is,
th e “baby blu es.” However, because th is patien t has had sym ptom s in cludin g suicidality or
3 weeks, the best diagn osis is m ajor depressive disorder (see also an swer to Question 130).
137. The answer is A. Flu oxetin e is th e on ly listed agen t th at is in dicated in th e m an agem en t
o b oth m ajor dep ressive d isord er an d b u lim ia. Bu p rop ion sh ou ld be avoided in p atien ts
with eatin g disorders becau se it lowers th e seizu re th resh old.
138. The answer is A. Typ ical 2-year-old ch ild ren rarely sit still or an y len gth o tim e or sh are
th eir toys with oth er ch ildren .
139. The answer is B. Typ ical in an ts begin to crawl on h an d s an d kn ees b etween 9 an d 11
m on th s o age. In typ ical in an ts, sittin g u n assisted is seen at ab ou t 6 m on th s, walkin g
u n assisted at abou t 12 m on th s, clim bin g stairs at abou t 18 m on th s, an d sp eakin g in two-
word sen ten ces at abou t 24 m on th s (an d see Ch ap ter 1).
140. The answer is D. Hosp itals are legally requ ired to p rovide care to an yon e n eedin g em er-
gen cy m an agem en t wh eth er th ey h ave th e m ean s to p ay or n ot via th e Em ergen cy
Med ical Treatm en t an d Active Lab or Act (EMTALA).
141. The answer is C. Th e p h ysician sh ou ld tell the p atien t th at h e or sh e is con cern ed abou t
h er an d th e b aby. Sin ce sh e is a com p eten t adult, on ly sh e can con tact law en orcem en t
to rep ort th e boy rien d’s beh avior. Sin ce th e ch ild is n ot born , th e state ch ild p rotective
agen cy can n ot in terven e. Talkin g to th e boy rien d will n ot be h elp u l an d in act m ay cau se
h im to in crease h is abu sive beh avior. Becau se th e p atien t p robably kn ows th at th e loss o
h er p reviou s p regn an cy was du e to h er boy rien d’s abusive beh avior (bu t yet h as ch osen
to con tin u e a relation sh ip with h im ), rem in din g h er o th at act is un likely to be h elp u l.
142. The answer is B. Th e best exp lan ation or th is clin ical p ictu re is illn ess an xiety disor-
d er. Desp ite n egative in d in gs, th is p atien t con tin u es to believe sh e h as lu p u s an d goes
“doctor sh op p in g,” th at is, sh e m akes an ap p oin tm en t with an oth er rh eu m atologist.
Th ere is n o in d ication th at th is p atien t is m alin gerin g (th ere is n o obviou s gain rom th e
sym p tom s) or actitiou s disorder (th ere is n o eviden ce o a desire to be con sidered a sick
p erson ), an d th ere is n o evid en ce o a p recip itatin g li e-th reaten in g stressor as in PTSD.
Con version disord er is n ot likely b ecau se th e sym p tom s are ch ron ic an d n ot n eu rological
an d th e p atien t is worried rath er th an in di eren t.
143. The answer is B. Th e n eu rotran sm itter m ost likely to b e m etabolized to MHPG
(3-m eth oxy-4-h yd roxyp h en ylglycol) is n orep in ep h rin e.
144. The answer is D. Th e m ost ap p rop riate description o th is patien t’s behavior is n orm al
bereavem en t. Occasion ally th in kin g th at on e does n ot wan t “to go on” is com m on in n or-
m al bereavem en t, an d this p atien t does n ot have suicidal p lan s. Because he sleeps an d eats
350 BRS Behavioral Science
n orm ally, m ajor dep ressive disorder is n ot likely an d his sym ptom s h ave n ot lasted lon g
en ou gh to diagn ose p ersisten t dep ressive disorder. Adju stm en t disorder (see Ch ap ter 13,
Table 13.1) can n ot be diagn osed i death o a loved on e was the li e stressor that preceded
th e sym p tom s.
145. The answer is B. Becau se th is girl is well in to p u berty (Tan n er stage 3 is th e m iddle stage
in ad olescen t sexu al develop m en t, see Ch ap ter 2), th e n ext step in m an agem en t is to
sp eak to th e girl alon e. Wh en ever th e p rob lem (h ere a p ossible eatin g disorder) in volves
p rivacy issu es in a p ostp u bescen t p atien t, th e doctor sh ou ld irst sp eak on ly to th e p atien t
(see Ch ap ter 21). It is best or th e p h ysician to take th e irst step in m an agem en t, re erral
to a sp ecialist is n ot ap p rop riate at th is tim e.
146. The answer is C. This 45-year-old m an is showin g eviden ce o alcohol withdrawal. The m ost
appropriate n ext step in the acute m an agem en t o alcohol withdrawal is a ben zodiazepin e
su ch as lorazep am . His h istory o drin kin g alcohol (as provided by his son ), the delayed
(36 h ou rs) on set o agitation an d disorien tation , an d elevated blood p ressu re an d p u lse
in dicate th at h e h as becom e dep en den t on alcohol. Halop eridol, lithiu m , an d p rop ran olol
are less likely to be use ul or im m ediate m an agem en t. Re erral to Alcoholics An on ym ous
typ ically is a lon g-term , n ot an im m ediate, strategy in m an agem en t o alcohol depen den ce.
147. The answer is D. In m en op au sal wom en , estrogen rep lacem en t th erapy (ERT) is m ost
closely associated with d ecreased risk or osteop orosis. ERT h as also been associated with
in creased risk o breast can cer (wh en adm in istered in com bin ation with p rogesteron e [P])
an d u terin e can cer (wh en ad m in istered with ou t P), bu t n ot with p reven tion o cardiovas-
cu lar disease or p sych iatric illn esses su ch as d ep ression .
148. The answer is D. This student’s sym ptom s o anxiety in a public situation (e.g., using public
restroom s) but not in other situations suggest that he has social anxiety disorder. This disorder
has lim ited the patient’s ability to socialize reely. While heterocyclic antidepressants such as
im ipram ine and clom ipram ine and benzodiazepines such as chlordiazepoxide and clonaze-
pam m ay be help ul, venla axine (as well as paroxetine, sertraline, and som e MAOIs) is the only
one o the listed agents that is approved to m anage social anxiety disorder (see Chapter 16).
149. The answer is A. Th is clin ical p ictu re m ost closely su ggests an orexia n ervosa. Callu ses
on th e kn u ckles (Ru ssell sign ) an d th e p arotid glan d abscess are evid en ce o sel -in du ced
vom itin g. Becau se h er BMI is b elow 17, th is you n g wom an sh e can be diagn osed with
an orexia n ervosa (with sel -in du ced vom itin g), n ot bu lim ia n ervosa or bin ge-eatin g disor-
der. Th is p atien t n eith er worries excessively ab ou t h er h ealth , as wou ld a p erson with ill-
n ess an xiety disorder, n or does sh e rep ort exp osu re to a li e-th reaten in g stressor, as wou ld
som eon e with acu te stress d isord er (an d see also an swer to Qu estion 132).
150. The answer is D. Mild in tellectu al disab ility an d u n u su al acial eatu res su ggest th at th is
p atien t h as Down’s syn d rom e. Down’s syn d rom e p atien ts wh o live to m iddle age com -
m on ly develop Alzh eim er’s disease. Ch rom osom e 21 is associated with both Down’s
syn drom e an d Alzh eim er’s d iseases.
151. The answer is E. Ab n orm al m otor m ovem en ts an d galactorrh ea ( lu id disch arge rom th e
n ip p les du e to in creased p rolactin ) are side e ects o risp eridon e. Arip ip razole, olan zap -
in e, zip rasid on e, an d ilop eridon e are less likely to be associated with th ese adverse e ects
(see Tab le 16.2).
152. The answer is A. Like oth er SSRIs, sertralin e is likely to cau se sexu al side e ects su ch as
delayed orgasm . Vilazod on e, m irtazap in e, d u loxetin e, bu p rop ion , an d ven la axin e h ave
lower rates o sexu al side e ects th an SSRIs (see Ch ap ter 16).
153. The answer is A. Tem azep am , a h yp n otic ben zod iazep in e, is in FDA p regn an cy category
X an d so sh ou ld b e avoided in p regn an t p atien ts. In con trast, bu sp iron e, zolp idem , an d
bu p rop ion are in category B, an d zalep lon is in category C (see Tab le 16.5).
154. The answer is E. Salivation , lacrim ation , rap id h eart rate, sweatin g, restlessn ess, an d
agitation are sign s o h eroin with drawal. Th u s, th e m oth er o th is in an t is m ost likely to
Comprehensive Examination 351
h ave been u sin g h eroin , an d th e in an t is in with drawal. With drawal rom PCP, cocain e,
m ariju an a, an d alcoh ol is u n likely to p rodu ce th is sym p tom p ictu re.
155. The answer is C. Th is p atien t is sh owin g eviden ce o n eu rocogn itive disorder with Lewy
bod ies. Patien ts with th is d isord er sh ow sign s o d em en tia sim ilar to th ose o Alzh eim er’s
disease (e.g., m em ory loss an d lan gu age d i icu lties), bu t th ey also sh ow p arkin son ian
sym p tom s (e.g., in e trem or an d gait distu rban ces), p sych otic sym p tom s (e.g., visu al h al-
lu cin ation s), m otor activity d u rin g REM sleep (REM sleep beh avior disorder [see Ch ap ter
10]), an d h yp ersen sitivity reaction s to an tip sych otic m edication s (e.g., m u scu lar rigidity).
Deliriu m is u n likely b ecau se th e sym p tom s h ave been p resen t over a lon g p eriod, an d
th ere are n o sign i ican t m edical in din gs. Hu n tin gton’s disease an d acqu ired im m u n ode i-
cien cy syn d rom e do n ot it th is clin ical p ictu re.
156. The answer is B. Wh ile sm okin g, red m eat an d alcoh ol, an d workin g as a p olice o icer
are related to lon g-term m ortality, th e leadin g cau se o d eath in p eop le u n d er age 35 is
m otor veh icle accid en ts, p articu larly wh en p assen gers ail to wear seat belts (an d see
Ch ap ter 24). So, as in ch ild ren (an d see Ch ap ter 24), th e m ost im p ortan t recom m en dation
or decreasin g m ortality in th e sh ort or lon g term or th is p atien t is or h er to con sisten tly
wear a seat b elt in th e car.
157. The answer is B. Th e m ost likely exp lan ation or th is stu d en t’s b eh avior th at b egan with a
stress u l li e even t (goin g away to college) is adju stm en t disorder (with dep ressive sym p -
tom s). Th is stu den t’s b eh avior is n ot typ ical h om esickn ess becau se h er sym p tom s are
a ectin g h er ability to u n ction (e.g., sh e is in dan ger o ailin g h er cou rses). Th e ab sen ce
o a p reviou s p sych iatric h istory or su icidal th in kin g an d th e act th at sh e can en joy tim e
with rien ds in dicate th at h er sym p tom s wou ld p robably n ot u l ill criteria or an an xiety
or m ood d isorder. Th e act th at th e stressor p rovokin g th e sym p tom s was n ot li e-th reat-
en in g ru les ou t acu te stress d isord er (see also Ch ap ter 13).
158. The answer is C. Th is 48-year-old m an wh o believes th at h is ellow em p loyees are con -
sp irin g to get h im ired is m ost likely to h ave delu sion al disorder, p aran oid typ e. Th is
disord er is ch aracterized by on e ch ron ic an d ixed n on b izarre d elu sion al system su ch as
th is p atien t’s belie in a n on existen t con sp iracy. Becau se th ere is n o oth er eviden ce o a
th ou gh t disorder, sch izop h ren ia is ru led ou t. Person ality disorders are n ot ch aracterized
by ran k ixed d elu sion s su ch as th e on e th is p atien t exh ib its.
159. The answer is E. This patien t with orthostatic hypotension, and prolonged QT interval is m ost
likely to be takin g a tricyclic an tidepressan t such as am itriptyline. Fluoxetine, bupropion ,
lorazepam , an d sertralin e are less likely than im ipram ine to cause these cardiac sym ptom s.
160. The answer is A. The physician’s m ost appropriate respon se to this patien t’s com m en t is
“Tell m e about your relation ship with your husban d.” The physician should irst get all o the
in orm ation about the issue be ore reassurin g the patien t or suggestin g a course o action .
161. The answer is C. Most correctly, th e p h ysician sh ou ld ollow th e cu rren t wish es o th e
p atien t an d n ot p u t h im on li e su p p ort. Th e cu rren t p re eren ce o th e p atien t was
exp ressed directly to th e d octor, so th e p rior written in stru ction s n o lon ger ap p ly. Th e
h osp ital ch ap lain , eth ics com m ittee, an d cou rt order are n ot in volved in th is decision
sin ce th e p atien t’s wish es h ave b een directly exp ressed to an d docu m en ted by th e doctor.
162. The answer is D. Th is wom an is sh owin g n orm al bereavem en t. In th e irst ew m on th s
a ter th e d eath o a close relative, m an y p atien ts h ave occasion al th ou gh ts th at th ey
sh ou ld h ave died in stead o th e loved on e. Becau se th is p atien t is gettin g back to h er
orm er li e-style (e.g., p layin g b ridge, cookin g) it is u n likely th at h e h as m ajor dep ressive
disord er. Persisten t dep ressive d isord er in volves at least 2 years o dep ressive sym p tom s.
Adju stm en t disord er can n ot be d iagn osed wh en b ereavem en t is a m ore ap p rop riate
descrip tion .
163. The answer is B. Th e m ost ap p rop riate diagn osis or th is m an ic p atien t is b ip olar I dis-
order. Wh ile a sin gle ep isod e o m an ia d e in es th is illn ess, th is p atien t also h as a h istory
o d ep ression . Th e gran diose religiou s b elie th at th is p atien t exh ibits is a delu sion , an d
352 BRS Behavioral Science
An tian xiety agen ts, 133, 174t, 175–176 Ben d er Visu al Motor Gestalt test, 51t
ben zodiazep in es, 174t, 175 Ben zod iazep in es (BZs), 41, 87, 175, 176t
n on -ben zodiazep in es, 174t, 175 in an xiety d isorders, 133
An ticon vu lsan ts, 126, 175 Bereavem en t, 28
An tidep ressan ts, 126, 133, 171–174, 172t, 173t β-blockers, in an xiety disorders, 133
e ects on sexu ality, 211, 211t Beta waves, 98, 99t
h eterocyclic agen ts, 172t, 173, 173t Bias, 293, 293t
MAOIs, 172t, 173, 173t redu cin g, in clin ical treatm en t trials, 294
or p ain m an agem en t, 251 Bin ge-eatin g d isorder, 151
an d seroton in , 40 Biogen ic am in es, 38–41
SNRIs, 172t, 173, 173t acetylch olin e, 40
SSRIs, 172t, 173, 173t dop am in e, 38–40
An tih yp erten sives, 176 h istam in e, 40
e ects on sexu ality, 211, 211t m easu rem en t o , 49–50
An tip sych otics, 126, 147, 169–170 m etabolites o , 38, 38t
adverse e ects o , 170t, 171t n orep in ep h rin e, 40
atyp ical, 170–171, 171t overview o , 38, 38t, 39
e ects on sexu ality, 211, 211t seroton in , 40
tradition al, 170, 170t Bip olar disord er, 34, 121, 123, 170. See also
An tisocial p erson ality d isord er, 148t Dep ressive an d bip olar d isord ers
An xiety, 78t, 133, 249 an ticon vu lsan ts or, 175
in eld erly, 26 gen etics o , 125t
organ ic basis o , 133 Birth rate, 1, 17, 17
p h ysiologic m an i estation s o , 132 Blin d stu dies, 294
An xiety disord ers, 132 Blu n ted a ect, 78t
an tian xiety agen ts or, 133 Bod y d ysm orp h ic d isord er, 135t
an tidep ressan ts or, 133 Bod y m ass in d ex (BMI), 150, 151
classi cation an d occu rren ce o , 132, 134t Bord erlin e p erson ality disord er, 149t
p sych ological m an agem en t o , 133 Boston n am in g test, 51t
review test on , 137–143 Brain
Ap gar scorin g system , 2, 3t an atom y o , 35–37
Ap lastic an em ia, 175 ch an ges, in Alzh eim er disease, 146
Ap om orp h in e h ydroch lorid e (Up rim a), 209 lesion s o , 36, 36t
Arip ip razole, 170 review test on , 42–48
ASD. See Au tism sp ectru m disord ers (ASD) Breath in g-related sleep d isorder, 102, 103t
Asen ap in e (Sap h ris), 170 Brie p sych otic d isord er, 115t
Asian Am erican s, 198–199 Brin tellix. See Vortioxetin e
Attach m en t Bru xism , 101t
in an t, 4 Bu lim ia n ervosa, 151
p resch ool ch ild, 6–7 ch aracteristics an d m an agem en t o , 152t
stu d ies o , 4 su b typ es o , 151
toddler, 5–6 Bu p ren orp h in e, 87–88
Attack rate, 297 Bu p rop ion , 173t
Atten tion , 78t Bu sp iron e (Bu Sp ar), 176, 176t
Atten tion de cit h yp eractivity d isord er (ADHD), in an xiety d isorders, 133
84, 161–162, 162t BZs. See Ben zodiazep in es (BZs)
Attribu table risk, 292
Au tism sp ectru m d isord ers (ASD), 160 C
au tism sp ectru m disorder, 160 Ca ein e, 84, 85t
n eu robiological etiology o , 161 CAGE qu estion s, or alcoh olism id en ti cation , 86
occu rren ce o , 161 Cap acity, 258–259
Aven tyl. See Nortrip tylin e Carbam azep in e (Tegretol), 126, 175
Aversive con dition in g, 66 Case-con trol stu dies, 291
Avoidan t p erson ality d isorder, 149t Catap lexy, 102
Awake state, 98 Cataton ic sch izop h ren ia, 114t
Cen ters or Disease Con trol an d Preven tion (CDC),
B 260
Babin ski ref ex, 4, 4t Cen tral n ervou s system (CNS), 35–36
Baby blu es, 2–3, 3t Cerebellu m , 66
Bad trip s, 88 Cesarean birth , 1
Barbitu rates, 41, 86–87, 211 Ch arcot-Marie-Tooth d isease, 35t
Bargain in g as stage o d yin g, 27 Ch ild abu se, 211
Bariatric su rgery, 150 p h ysical, 222t
Basal gan glia, 36t, 221 role o p h ysician in , 214
Beck Dep ression In ven tory-II (BDI-II), 77t sequ elae o , 211
Beh avioral th erap ies, 188, 188t sexu al, 211–213
Bell an d p ad ap p aratu s, 163 typ es o , 211
Bell-sh ap ed d istrib u tion . See Norm al d istrib u tion Ch ild cu stod y, 196
Index 355
Don ep ezil (Aricep t), 41 Fem ale sexu al in terest/ arou sal disorder, 208t.
Dop am in e (DA), 38, 85, 100, 113 See also Sexu al dys u n ction
stim u lan ts e ect on , 85 Fem ale orgasm ic disorder, 208t
Doxep in , 172t Fetal alcoh ol syn drom e, 86
Dream s, 57 Fetish istic, 209t
Dru g-assisted in terview, 52 Fish er’s exact test, 311
DSP. See Dep ression with season al p attern (DSP) Fixed in terval rein orcem en t, 67t
DTs. See Deliriu m trem en s (DTs) Fixed ratio rein orcem en t, 67t
Du loxetin e (Cym b alta), 133, 172t, 173t Flat a ect, 78t
Du rab le p ower o attorn ey, 262 Flu m azen il, 87, 176
Dyssom n ias, 100 Flu oxetin e (Prozac), 133, 172t, 173t
Dyston ia m u scu loru m d e orm an s, 35t Flu p h en azin e (Prolixin ), 170
Flu p h en azin e d ecan oate, 170
E Flu razep am (Dalm an e), 176t
Eatin g d isord ers, 150. See also An orexia n ervosa; Flu voxam in e (Lu vox), 172t, 173t
Bu lim ia n ervosa; Bin ge-eatin g d isorder Folstein Min i-Men tal State Exam in ation (MMSE),
Ebstein’s an om aly, 175 51, 51t, 52t, 259
Ecstasy, 84 Food an d Dru g Adm in istration (FDA),
Ego, 58t 176, 177t
Eld erly Foster care system , 4
abu se o , 211, 212t, 214 Fragile X syn drom e, 35t
alcoh ol-related disorders in , 27 Free association , 187
an xiety in , 27 Freebase, 84
deliriu m in , 146 Free f oatin g an xiety, 78t
dep ression in , 26 Freu d , Sigm u n d , 5
m em ory p roblem s in , 146t Freu d’s th eories o m in d , 57
osteop orosis in , 25 stru ctu ral th eory, 58, 58t
sleep p attern s ch an ge in , 26 top ograp h ic th eory, 57–58
Electrocon vu lsive th erapy (ECT), 177 Fron tal lob es, 36t
adm in istration o , 177–178 Fron totem p oral n eu rocogn itive disord er, 148
or dep ressive disorder, 126 Frotteu ristic, 209t
p rob lem s associated with , 178 Fu ll scale IQ (FSIQ), 75
uses o , 177 Fu n ction al MRI ( MRI), 51t
Electroen cep h alogram (EEG), 51t
Electroen cep h alograp h y, 50, 51t G
En cop resis, 163 Galan tam in e (Rem in yl), 41
En docrin e u n ction , evalu ation o , 50 Galvan ic skin resp on se, 52
En u resis, 163 γ-am in obu tyric acid (GABA), 41, 85, 211
Ep id em iology Gate con trol th eory, o p ain , 251
de n ition o , 290 Gau ssian distribu tion . See Norm al distribu tion
in ciden ce, 290–291 Gen d er d ysp h oria, 206
p revalen ce, 290–291 Gen d er iden tity, 206, 206t
review test on , 298–305 Gen itop elvic p ain -p en etration d isord er, 208t
Erectile d ys u n ction , 209, 210 Gen d er role, 206t
Erikson , Erik, 5 Gen eralized an xiety disord er (GAD), 132, 134t, 176.
Escitalop ram (Lexap ro), 133, 172t, 173t See also An xiety d isord ers
Eszop iclon e (Lu n esta), 176, 176t Gen etic d isorders, testin g or, 260
Euth an asia, 263 Gen etics
Euth ym ic m ood, 78t o Alzh eim er d isease, 146
Evoked EEG (evoked p oten tials), 51t beh avioral, 34, 35t
Exam in ation , review exercise or, 317–352 o sch izop h ren ia, 113
Exh ibition istic, 209t Geriatrics, 25
Exp an sive m ood, 78t Geron tology, 25
Extin ction , 67, 67t Glasgow Com a Scale (GCS), 51, 51t, 52t
resistan ce to, 68 Glu tam ate, 41, 113, 147
Glycin e, 41
F Grie reaction
Factitiou s d isord er, 136, 136t typ ical, 27–28
Fam ily, 195 vs. com p licated, 28t
ch ildren in , 196 Grou p th erapy, 189, 189t
exten ded, 195
review test on , 200–204 H
sin gle-p aren t, 196 Hal way h ou se, 279t
tradition al n u clear, 195 Hallu cin ogen s, 88
Fam ily risk stu dies, or gen etics o b eh avior, 34 lab oratory n d in gs or, 90t
Fam ily th erapy, 189, 189t LSD an d PCP, 89
or con duct disorder, 162 m an agem en t o abu se o , 88t
or op p osition al de an t disorder, 162 m ariju an a, 89
Fear, 78t, 132 u se an d with d rawal o , e ects o , 89t
Index 357
Obsessive-com pulsive personality disorder, 148t, 149t m ed ical p ractice, 232–233, 233t, 234t
Occip ital lobes, 36t, 211 review test on , 238–247
Odds ratio, 292 Piaget, Jean , 5
Olan zap in e (Zyp rexa), 126, 170 Pickwickian syn drom e, 102
Olep tro. See Trazod on e Placebo resp on ses, 294
Op eran t con dition in g PMDD. See Prem en stru al dysp h oric d isorder
eatu res o , 67–68, 67t (PMDD)
p rin cip les, 66 PNS. See Perip h eral n ervou s system (PNS)
sh ap in g an d m odelin g, 68 Poin t p revalen ce, 290
Op ioids, 87 Porp h obilin ogen , 50
bu p ren orp h in e, 87–88 Positive p redictive valu e (PPV), 295
h eroin , 87, 87t Positive rein orcem en t, 67, 67t
laboratory n d in gs or, 90t Positron em ission tom ograp h y (PET), 51t
m an agem en t o abu se o , 88t Postp artu m m atern al reaction s, 2–3, 3t
m eth adon e, 87–88, 87t Post-trau m atic stress disorder (PTSD), 133, 134t.
use an d with d rawal o , e ects o , 88t See also An xiety d isord ers
Op p osition al de an t d isorder, 161–162, 162t Power, 309
Organ don ation , 263 Prad er-Willi syn drom e, 35t
Orgasm ic disorder, 208t. See also Sexu al dys un ction Precision , in m ean estim ation , 307
Orlistat, 150 Precon sciou s m in d, 57
Osteop orosis, in elderly, 25 Pred ictive valu e, 295
Overeaters An on ym ou s (OA), 189 Pregn an cy
Oxcarbazep in e (Trilep tal), 175 cocain e u se du rin g, 84
Oxytocin , 161 p sych oactive agen ts in , 176, 177t
teen age, 17
P Prem atu re birth , 1
Pain Prem atu re ejacu lation , 208, 208t, 209. See also
in ch ildren , 251 Sexu al d ys u n ction
ch ron ic, 251 Prem en stru al d ysp h oric d isord er (PMDD), 122
disorder, 135t Presch ool ch ild
m an agem en t, 251 attach m en t, 6–7
Palip eridon e (In vega), 170 ch an ges at 6 years o age, 7
Palm ar grasp ref ex, 4, 4t ch aracteristics o , 7
Pam elor. See Nortrip tylin e m otor d evelop m en t o , 6t
Pan ic attacks, 133 reaction to illn ess, 18
Pan ic d isorder, 133, 134t review test on , 8–14
Param etric tests, 310 social d evelop m en t o , 6t
Paran oid p erson ality d isord er, 148t, 149t verb al an d cogn itive d evelop m en t o , 6t
Parap h ilias an d p arap h ilic disord ers, 209–210, 209t Prescrip tion d ru gs, e ects on sexu ality, 211, 211t
Parasom n ias, 100 Prim ary h yp ersom n ias, 101t
Parietal lob es, 211 Prim ary p rocess th in kin g, 57
Paroxetin e (Paxil), 133, 172t, 173t Progressive m yoclon ic ep ilep sy, 35t
Passive-aggressive p erson ality disord er, 148t, 149t Projection , 59t
Patien t com p lian ce, 49 Prop ran olol (In deral), 133
Patien t-con trolled an algesia (PCA), 251 Prosth etic d evices, 209
Patien t p rotection an d a ord able care act (ACA). Protrip tylin e (Vivactil), 172t, 173t
See also Obam acare Pseu dodem en tia, 26
Pedop h ilia, 209t Psych iatric care, seekin g o , 232
Period p revalen ce, 290 Psych iatric disord ers, in ch ild ren
Perip h eral n ervou s system (PNS), 35–36 atten tion de cit/ h yp eractivity disorder, 161–162
Perp h en azin e (Trila on ), 170 elim in ation d isord ers, 163
Persisten t dep ressive d isorder, 122, 124 review test on , 164–168
Persisten t vegetative state (PVS), 262 selective m u tism , 161
Person ality disorders (PDs), 148 sep aration an xiety d isord er, 163
ch aracteristics o , 148, 148t, 149t Tou rette’s disorder, 163
classi cation o , 148, 148t, 149t Psych iatric h istory, 76
m an agem en t o , 149 Psych iatric sym p tom s
Person ality tests, 76, 76t biogen ic am in es, m easu rem en t o , 49–50
Ph en cyclidin e (PCP), 88, 89, 211 dru g-assisted in terview, 52
Ph en elzin e (Nardil), 172t, 173t electroen cep h alogram , 50–51
Ph en term in e (Ion am in ), 150 en docrin e u n ction , 50
Ph en ylketon u ria, 35t galvan ic skin resp on se, 52
Ph obias, 132, 133, 134t. See also An xiety d isorders n eu roim agin g, 50–51
Ph ysician -assisted su icide, 263 n eu rop sych ological tests, 51–52
Ph ysician -p atien t relation sh ip overview, 49
adh eren ce, 233–235, 236t p sych otrop ic d ru gs, 49–50
breakdown o , 263 review test on , 53–56
clin ical in terview, 235–237, 237t sodiu m lactate ad m in istration , 52
360 Index
U X
Un con dition ed resp on se, 66 Xen ical. See Orlistat
Un con dition ed stim u lu s, 66
Un con sciou s m in d, 57 Z
Un doin g, 60t Zalep lon (Son ata), 176, 176t
Un ited States Medical Licen sin g Exam in ation Zidovu din e (AZT), 212
(USMLE), 75 Zin c, 250t
Zip rasidon e (Geodon ), 170
V Zolp idem (Am bien ), 176, 176t
Validity, 294 z score, 307, 307t
Valp roic acid (Dep aken e, Dep akote), 175 Zyban . See Bu p rop ion