Behavioral Sciences Exam 1 Study Guide:

Defense Mechanisms:
• Core psychoanalytic theory:
o What we reveal → the conscious mind
o What we conceal → the unconscious mind
• Theory of the mind:
o Id → instinctive biological drives and desires → COMPLETELY UNCONSCIOUS MIND
o Ego → logical and language-based problem solving → controls the impulses of Id and works to compromise
between the Id and the Superego
§ The main goal of the ego is to reduce fear, anxiety, and distress
§ Ego defenses are how the ego solves problems and reduces fear → defenses are unconscious, change
with circumstances, can be useful or harmful, and vary by intensity → can be primitive, basic or mature
• Primitive defenses:
o Projection → attributing one’s own desires, thoughts, or emotions onto someone else
o Denial → first stage of grief → refusal to accept external reality because it is too
threatening
o Splitting → perceiving others and the world as either all goof or all bad
o Displacement → redirects emotions or impulses to a less threatening target
Know all o Regression → temporary reversion of behavior to earlier more child-like behavior
defense o Somatization → psychological experiences manifest as physical symptoms
mechanisms o Blocking → temporary inability to remember
o Acting out → covering up true feelings by excessive action or sensation
o Introjection (identification) → internalizing the behaviors or emotions observed in
others with people we admire
o Reaction formation → converting unacceptable wishes or impulses into their
opposites → LOOK FOR AN OVER-REACTION
o Isolation of affect → separation of feelings from ideas and events → Facts without
feelings
o Intellectualization → concentrating on the intellectual components of a situation so
as to distance oneself from the associated anxiety-provoking emotions
o Undoing → performing an action that is believed to fix or reverse an unacceptable
behavior
o Rationalization → convincing oneself that no wrong happened and that the
unacceptable is acceptable → making excuses, inventing reasons to justify the
behavior
o Passive aggressive → aggression or hostility towards other that is expressed indirectly
o Disassociation → temporary or drastic modification of one’s personal identity to avoid
emotional distress
• Mature defenses:
o Humor → overt expression of ideas and feelings in a way that brings pleasure to others
o Suppression → the conscious and intentional decision to delay paying attention to an
emotion or need in order to cope with the present reality
o Sublimation → transformation of negative emotions into positive actions, behaviors
and emotions
o Altruism → constructive service to others that brings pleasure and personal
satisfaction
o Transference → UNCONCIOUS BUT NOT A DEFENSE MECHANISM →
emotions and reactions to someone in the past are unconsciously projected onto
someone in the present
o Superego → moral conscious based on ideal values of society → aspiration to be a good person
 Step 1 Test Question

A 24-year-old model worries about her job security

when a more experienced model is hired. She begins
to throw temper tantrums and continuously makes
negative statements about the new employee behind
her back to the boss. Which of the following defense
mechanisms is the model exhibiting?

A. Regression
B. Denial
C. Reaction Formation
D. Splitting
E. Sublimation

Kaplan USMLE Step 1 Qbook (7th Edition, 2015)

An 84-year-old woman who fondly
reminds you of your grandmother
presents in the Urgent Care Clinic with a
urinary tract infection. You find it hard
to ask whether she has difficulty
urinating and whether she is sexually
active.
t e r-t ra n s fe re n c e ?
ra n s fe re n c e o r C oun
T
 Step 1 Test Question

A 27-year-old swimmer who feels insecure about her

athletic abilities criticizes her teammates for not
being talented enough. Which of the following ego
defense mechanisms is she displaying?

A. Displacement
B. Passive Aggressive
C. Reaction Formation
D. Projection
E. Sublimation

Kaplan USMLE Step 1 Qbook (7th Edition, 2015)

 Lifespan Development:

• Development is the pattern of change that begins at conception and continues through the lifespan → most
development involves growth, but it can also involve decline
• Piaget’s Cognitive development theory → children actively construct knowledge as they manipulate and
explore their world and this cognitive development takes place in stages → argues that children ADAPT to
their surroundings
o Schemes → organization and structure of the world the children live in
o Assimilation → incorporation of new information into already learned knowledge
o Accommodation → adjustment based on learned knowledge
Cnowthisentirechart
TYPICAL AGE RANGE: DESCRIPTION OF STAGE: DEVELOPMENTAL
PHENOMENA:
Birth to about 2 years Sensorimotor: experiencing the world Object permanence → objects
through senses and actions such as continue to exist despite not being able
touching, looking, mouthing and to see it
grasping
Stranger anxiety
2 to about 6/7 years Preoperational: representing things Pretend play
with words and images and the use of
intuitive rather than logical thinking → Egocentrism → the inability to
starting to organize date distinguish one’s own perceptions,
thoughts, and feelings from those of
others

Language development
7 to 11 years Concrete operational: thinking logically Conservation → the knowledge that
about concrete events and grasping the quantitative properties of an object
concrete analogies and performing such as mass, volume, or number
arithmetic operations remain the same despite change in
appearance

Mathematical transformations

Develops transitivity

Seriation → the ability to order stimuli

along a quantitative dimension
12 through adulthood Formal operational: abstract reasoning Abstract logic
Potential for mature moral reasoning
• John Bowlby: Attachment → both the caregiver and the infant are biologically pre-disposed to form a close
emotional bond
o An increase in response, holding, and calming between an caregiver and child will increase the
attachment
o For the first 12 months, infants should be comforted when they are upset as they form basic trust
o Insecure attachment → unresponsive or insecure parenting can lead to insecure babies →
unresponsive mothering is related to low IQ mothers, young mother, and emotionally immature
mothers
cnowthisentirechart
• Erik Erikson: emphasized the impact of the environment on psychosocial development → believe we move
through stages throughout our lives and each stage has a conflict or life task that we must master to grow
APPROXIMATE AGE: PSYCHOSOCIAL CRISIS/TASK:
Infant-18 months Trust vs. Mistrust → infants learn that they can or cannot
trust others to take care of their basic needs → main life task:
feeding
18 months-3 years Autonomy vs. Shame/Doubt → children learn to be self-
sufficient in activities; if they are restrained too much they
learn to doubt their abilities and feel shame → main life task:
toilet training and walking
3-5 years Initiative vs. Guilt → children learn to assume more
responsibility by taking the initiative but will feel guilty if
they overstep limits set by parents → main life task:
independence in play and activities
5-13 years Industry vs. Inferiority → children learn to be competent by
mastering new intellectual, social and physical skills or feel
inferior if they fail to develop these skills → main life task:
school
13-21 years Identity vs. Confusion → adolescents develop a sense of
identity by experimenting with different roles → main life
task: peer relationships
21-39 years Intimacy vs. Isolation → adults form intimate relationships
with others or become isolated because of failure to do so
→ main life task: loving relationships, intimacy, work and
career
40-65 years Generativity vs. Stagnation → middle-aged adults feel the
need to help the next generation or they stagnate → main
life task: parenting and career
65 and older Integrity vs. Despair → older adults assess their lives and
develop sense of integrity if they find their lives have been
meaningful and the develop a sense of despair if not
meaningful → main life task: reflection and acceptance of
one’s life
• How old is an older adult? 65 years and older → we do not use the word elderly anymore, it is derogatory
• Graying of America:
o In 2000, 35 million Americans were 65+
o In 2050, 89 million Americans will be 65+
o In 2030, 1 in 5 Americans will be 65+ (20% of population)
o Chronic conditions are now the leading cause of death for older adults → heart disease and cancer are
the TOP killers
o For adult males over 75 there is a SIGNIFICANT increase in suicide → they are the highest risk
group
§ Older patients do attempt suicide less often than younger patients but are more likely to
complete it
§ Most older adults who complete suicide were in their first episode of depression and has seen
a physician within the last month of life
• THE BEST predictor of nursing home admissions for older adults is HISTORY OF FALLS!
 Step 1 Test Question
A girl is brought to the pediatrician for a well-child
visit. The mother reports no problems with her
daughter. Physical examination is unremarkable, and
the child is up-to-date on her immunizations. Further
evaluation reveals the girl understands that the volume
of a liquid poured out of a narrow glass remains the
same when poured into a wider glass. This child is at
which of Piaget’s stages of intellectual development?

A.Concrete Operations
B. Formal Operations
C. Preoperational
D.Sensorimotor

USMLE Step 1 Qbook (7th Edition, 2015)

 Step 1 Test Question

The best predictor of nursing home admissions for

the elderly {older adults} is which of the following?

A.Family support system

B. History of falls
C. Incontinence
D.Marital Status
E. Wandering

Kaplan USMLE Step 1 Self-Study Online Quiz (2020)

Child Milestones:

• Milestones are normative markers at the median ages, but are not always achieved at the exact date, so they vary
• Hands and feet are the first parts of the body to reach adult size → motor development follows set patterns
o Normal progression: FIRST BIRTHDAY = FIRST WORDS AND FIRST STEPS

‘
• Required screenings:
o One of the primary goals of routine preventative health care is to ensure that a child is developed normally
o The American Academy of Pediatrics recommends developmental surveillance at every well-child visit and
developmental screening using formal validated tools at 9 months, 18 months, and 24 months or 30 months
o Screening should occur when parents express concerns or whenever a parent or provider expresses concerns
o Additional autism specific screenings are recommended at the 18-month and 24-month visits
• Tools for Pediatric Assessment:
o Greet children first, followed by parents
o Be very cautious with leading questions because children want to please authority figures
o Use child-appropriate vocabulary
o Sense of time/history often not accurate, especially for school-age children
o Molehills may actually be mountains
o Examining infants:
§ Talk to the baby
§ Listen to the heart first if baby is asleep or quiet
§ Have a toy for baby to hold
§ Make it brief
§ Use parents help
o Examining preschoolers:
§ Observe the child wandering in the room and watch the interactions between child and parent
§ Ask some history from the child
§ Let the child handle instruments
§ Ask the child to draw a man or a woman
o Examining School Age Children
§ Relatively healthy time
§ Assess for enuresis → bed-wetting/soiling
§ Ask about school refusal
§ Ask about learning problems
§ Use multiple sources
o Standardized Child Screenings
§ Measure developmental progress
§ Involve various demonstrations of behavioral functioning
§ Two common tools are Denver Developmental Assessment Tool and Bailey Infant Scales
§ Additional resources: CDC Development Milestone checklist and Developmental Milestones chart
for 1-12 years of age
 X

nobabbling
Adolescence and Adulthood:

• Developmental aspects of adolescence:

o Know what is normal and how patients present when abnormal
§ Biological and physical changes
• Hormone output increases → Males increase in testosterone and females increase in estrogen
• Physical growth → height spurt (females first), weight gain (fat vs. muscle), and appearance
• What is early and late?
o Over the last 100 years, the average age of puberty has dropped a total of about 4 years
o Girls average: 11 years old (range is 8-14)
o Boys average: 12-13 years old (range is 9-16)
• These changes can lead to awkward appearances during adolescence as well as coordination
problems
§ Changes in neurological and cognitive function
§ Social and emotional changes
• Early adolescence (11-14 years)
o Adjusts to physical changes of puberty
o Peer groups tend to be the same gender
o Needs for privacy increased
o Sexual curiosity and masturbation are common
§ Many young adolescents think that their peers are sexually active however,
75% are not engaging in sexual intercourse
• 13% have vaginal sex by 15
• 70% have vaginal sex by 19
§ Average age for first intercourse:
• Males = 16.9
• Female = 17.4
o Crushes on adults are common
o DO NOT say: “Everyone goes through that” → makes their feelings minimized
• Middle adolescence (15-17 years)
o Conflict with authority increases
o Experimentation with sex and drugs increases
o Experimentation with different images
o Peer group is mix-gendered
o Feelings of invincibility and risk taking increases
o Worse medication adherence than in children
• Late adolescence (18-21 years)
o Individual relationships become more important
o Sense of concern for others and morality develops
o Awareness of consequences of risky behavior increases
o More focus on relationship
o Sex is an expression of caring and intimacy
o Less focus on peer group than relationships
§ Risk-taking behaviors
• Explanation for the increased risk taking is proven by structural brain changes
• The prefrontal cortex does not have the blood flow of the adult pattern and thus does not
mature till early to mid-20’s
• The amygdala, which is responsible for emotional reactivity, is increased in activation causing
an increase in unpleasant affect
§ Emergence of sexuality
• Who influences adolescents?
o Most adolescents identify with media role models → conformity most extreme in ages 11-12
o Parental values influence education, careers, and religious/political beliefs
o Peer values influence music, appearance, sexual behavior, and choices about substance use
• It is normal for adolescents to:
o Experience egocentrism: “No one feels the way I do”
o Argue for the sake of arguing and to constantly find fault in the adult position
o Jump to conclusions
o Be self-focused
o Be overly dramatic, moody or self-conscious
o Show less affection to parents

• Red Flags for psychiatric illness during adolescence:

o Unsafe use of alcohol and drugs
o Unsafe sex
o Delinquency, crime, violence
o Persistent depressed or irritable mood
o Marked change in school achievement and or behavior
o Social withdrawal
• Advanced Interviewing for Adolescents: BIHEADS
o Biological factors
o Image
o Home and health
o Education and Employment
o Activities
o Drugs and diet
o Sex and suicidal thoughts
• Confidentiality and the law:
o Be SURE to talk with adolescents about confidentiality and “deal breakers”
o If you are unsure of whether confidentiality can be kept, ask a preceptor
o It always depends on the low of the jurisdiction
o Parent’s involvement can assist with compliance and confidentiality concerns
o Trust is CRITICAL, the doctor must take the initiative and explain confidentiality to the teenage patient
• Physician Response Guidelines:
o Self-check for ageism
o Listen non-judgementally and listen more than you speak
o Acknowledge their emotional state
o Make statements short and limit advice that is not sought out
o “Why” questions may put interviewees on the defensive and cause discomfort → these questions lack
empathy, show little respect for the client, and no sign of positive regard
• Adult Development:
o Challenges in Early Adulthood:
§ Marriage rates have dropped during adulthood, with the highest rate of divorce for this age group
(50%)
§ Marital satisfaction is likely to drop drastically during child-rearing years, which is related to stress
§ Divorce can lead to psychological stress, legal/financial issues, and reworking social networks
§ Infidelity in adulthood: 25-75% of men have been unfaithful and 15-50% of women have been
unfaithful → risk factors include new career stress, traveling alone, depression, children demanding
attention, and death of a parent/child/sibling/friend
o Challenges in Middle Adulthood:
§ Employment: when job satisfaction becomes so important, unemployment has serious consequences
such as alcohol use disorder, violence, suicide, and mental illness
§ Chronic illnesses begin to emerge at this time, which will lead to the need for behavioral/schema
change to adapt which can include modifying lifestyle, tolerating body changes, maintaining positive
outlook, maintaining positive relationships
A 15 year old female recently began hanging out with
a new peer group. Now she becomes irritable and
withdrawn when her parents ask about her new
friends. She has been missing curfew and refuses to
tell her parents where she has been. She is also
beginning to fail in some of her classes and skips
classes to be with her new friends. Her behavior
includes red flags for what?

A. Normal adolescent
behavior
B. Substance use
C. Oppositional defiant
disorder
D. Conduct Disorder
E. Normal separation
anxiety
Patient is a 42 year old male that is being seen for
headaches. He reports that he has started a new job
that has required for him to travel extensively, and
although challenging he has ‘really enjoyed’ it. He
has 3 children, and his wife is currently pregnant with
their fourth. They have also put an offer in for a new
house. Which of the following would patient be at
risk for?

A. A. High blood
pressure
B. B. Alcohol use
C. C. Infidelity
D. D. Chronic
Fatigue
E. E. Infection
A 13-year old boy comes to the physician accompanied by his mother for a routine
physical examination and follow-up of his type 1 diabetes mellitus. The boy appears
irritated, and his mother begins the visit by exclaiming, “Here’s the doctor, hes going to
tell you how badly you have been doing.” Laboratory tests show a random blood glucose
of 350 mg/dl and an HbA1c of 9% (normal <6-7%). When the physician asks the patient
how he is doing with his insulin, the mother interrupts and shouts, “He never
remembers to use it!” When asked about the diet, the mother puts her hands on her
hips, glares at her son and says, “pizza, soda and candy!”. Which of the following with
the best initial response?
A. Acknowledge the mother’s concerns and ask to speak with the patient alone
B. Arrange for child protective services home visits to assess for child abuse
C. Arrange for a dietician to meet with the patient and mother
D. Ask if the patient agrees with his mother’s statements about insulin use and
diet
E. Explain an increased insulin dose will improve the patient’s glucose control
F. Explain to the mother that her critical tone is not helpful.
Pregnancy and Infancy:

• Premature: LESS than 37 weeks gestation

o If a woman goes into labor before 37 weeks, it is called preterm labor
o The more premature the baby, the less it will survive
o A baby’s chance to survive increases 3-4% per day between 23-24 weeks or gestation and 2-3% per day
between 24-26 weeks of gestation
o After 27 weeks, the rate of survival increases at a much slower rate because survival is high already
o Prematurity correlates:
§ Low socioeconomic status
• HIGH socioeconomic status correlates NEGATIVELY with infant mortality
• RISK: Financial strain → 28% of employed pregnant women have NO paid maternity leave
§ Poor maternal nutrition (lack of prenatal care)
• Breastfeeding is best for the infant, but can be a challenge for working mothers
• Infants who are malnourished in their first year may suffer from marasmus, wasting away of
body tissues caused by severe protein-calorie deficiency → leads to underdevelopment of
child’s growth
§ Teenage pregnancy
• Adolescents are the highest risk group for premature delivery and birth defects due to
inadequate prenatal care, drug/alcohol use, smoking and second-hand smoke exposure,
economic factors, family pattern of early pregnancy and lack of social support
§ Increased maternal age (greater than 35 years old)
• Increased risk for infertility, genetic complications, and delivery complications
§ Multiple births
§ Multiple pregnancy (twins, triplets, etc.) makes up about 15% of premature births
§ Use of tobacco, cocaine, and amphetamines
§ Drinking alcohol
• One of the most preventable causes of intellectual disabilities in the US
• Causes fetal alcohol syndrome → growth retardation, CNS manifestations, delayed
development, seizures, ADD, ADHD, intellectual disability, and PHILTRUM
§ Domestic abuse
• Maternal mental health:
o Depression: 13% at 32 weeks and 17% at 37 weeks
o Depression Paripartum type: 8-19% of women
o Intimate partner violence: 4-8% during pregnancy → increases during pregnancy and
higher for unwanted pregnancies
§ Underweight or overweight: KNOW BOTH grams and pounds
• VERY LOW: less than 3.5 pounds or 1500 grams
• LOW: between 3.5 pounds and 5.5 pounds or 2500 grams
o Increased risk for disability in learning, speech, emotional, intellectual, and physical
o Increased needs for special education placement
• Normal: more than 5.5 pounds or 2500 grams
§ High levels of stress
• Maternal corticosteroids can cross the placental barrier and affect the cardiovascular system
of the infant → correlated with low birth weight, hyperactivity, irritability, sleep problems, and
poor feeding
§ Zika virus: microcephaly, impaired growth, eye defects, and hearing loss
• Full term: Between 37-42 weeks gestation
• Post-term: more than 42 weeks gestation
 • APGAR Score: Perform this exam at 1 minute, 5 minutes, and repeat at 10 minutes → problems arise with a score of
7 or less
KNOWhowto usethis chart
SIGN: SCORE: 0 SCORE: 1 SCORE: 2
Appearance on skin color Blue, yellowish Body pink, limbs blue Entire body pink
Pulse/Heart rate None Less than 100 bpm More than 100 bpm
Grimace/Reflex Irritability No response Weak response Vigorous response
Activity/Muscle tone Limp and no movement Weak, no resistance Limbs resistant
Respiration None Shallow/irregular Normal crying/breathing
• Reflexes: S beableto nameandknowwhenthereflexissupposedtodisappear
o Rooting reflex → searching for nipple → gone by 4 months
o Eye-blink reflex → reflexive blinking that protects baby from bright lights and foreign objects
o Sucking reflex → babies instinctively begin to suck at objects placed in the mouth → gone by 2 months
o Moro reflex → when the baby hears a loud noise or their head falls back, they may instinctively extend arms
out, arch their back and bring arms toward each other as though they are trying to grab someone → gone by
3-6 months
o Palmar and Plantar Grasp reflex: gone by 4-5 months
§ Palmar → curling of fingers around an object that touches the palm
§ Plantar → stroke bottom of foot and their toes curl under
o Tonic Neck (Fencer) reflex → when the head turns, same-side limbs stretch and opposite-side limbs curl →
this is present at birth and normally disappears by 4 months
o Babinski reflex → occurs when the great toe flexes toward the top of the foot and the other toes fan out after
the sole of the foot has been firmly strokes → this often disappears when a baby begins walking → gone by
12 months
o Galant reflex → strokes along one side of the spine when in face down position causes lateral flexion of lower
body toward stimulated side
• Sensory development:
o Discerning faces → 1 month old babies appear to be able to distinguish mother’s face from stranger’s as long
as they hear the mother’s voice as well
o At 3 months, baby can distinguish mother from stranger face alone
o Vision:
§ Birth → 20/600 which is legally blind
§ 6 months → 20/100
§ 9 months → 20/60 → they can see across the room
§ 24 months → 20/20
o Depth perception:
§ Three-dimensional vision does not fully develop until about 4 months
§ Full depth perception at 6 months
§ Brain needs experience to develop 3-D vision
o Hearing:
§ By 1 month → babies can distinguish between the smallest variation in sound
§ By 6 months → developed the ability to understand and make all sounds necessary for language
o Touch:
§ Newborns have a well-developed sense of touch and use this sense a lot
o Smell:
§ 1-day old infants can distinguish between some smells
§ 1 ½ month old infants can distinguish smell of mother from strangers
o Taste:
§ Newborns prefer the taste of sweet and salty and dislike bitter-tasting things
§ Gustatory sensations stimulated and developed by ingestion of amniotic fluid
Checking a 1-month-old infant, a physician strokes the sole
of the infant’s foot. The infant’s toes splay immediately.
Which of the following newborn reflexes is the physician
testing:

A. Babinski reflex
B. Grasp reflex
C. Moro reflex
D. Rooting reflex
E. Stepping reflex
 4
Patient is a newborn girl that presents with shallow and l
z
irregular breathing, and her body is all pink. Her heartbeat is 88
beats/mi and her reflexes are vigorous and her legs are resistant
to applied pressure. What Apgar rating would patient receive? z
2

1 1421 2 2 8
A. 4
B. 5
C. 6
D. 7
E. 8
Shouldbegone
by 2 months
 7 I

11
I

0
Psychiatric Evaluation and Mental Status Exam:

• Psychiatry is the branch of medicine focuses on the diagnosis, treatment, and prevention of mental, emotional and
behavioral disorders
• DSM-5 Definition of Mental Disorder: A mental disorder is a syndrome characterized by a clinically significant
disturbance in an individual’s cognition, emotion regulation, or behavior that reflects a dysfunction in the
psychological, biological, or developmental processes underlying mental functioning. Mental disorders are usually
associated with significant distress or disability in social, occupational or other important activities.
• Diagnostic Coding: For each psychiatric disorder, the ICD-10-CM code is provided and is used by medical/mental
health professionals for the code of billing

• How is psychiatric evaluation different than medical history taking?

o Identify clinical symptoms and their severity
o Onset of symptoms
o Chronicity and frequency of symptoms
o Precipitating events
o Risk
o Alcohol and drug use
o Degree of impairment in functioning
o Will include a mental status exam
o Identifying patient information: Age, gender, sex, relationship status, parental status, occupation, notable
social characteristics, occasion patient was first seen, source of referral
o Chief complaint: use the patient’s own words and include approximate duration and history of chief complaint
if possible
o Medical History: hospitalizations, surgeries, current medications, allergies
o Psychiatric history: precious psychological diagnoses and hospitalizations, drug and alcohol use and treatment,
trauma/stress history, and mental health treatment
o Psychosocial History: educational history, occupational or vocation history, family history, developmental
history, legal history, social history, and spiritual/cultural considerations
o Risk assessment: suicidal ideation, homicidal ideation, overall assessment of risk
§ Thoughts of suicide now? History of suicide attempts? Past thoughts of suicide?
• Mental Status Exam: Series of observations and examinations at one point in time → paints a picture of a patient’s
appearance, thinking, emotion and cognition
o We use the mental status exam to assess need for hospital admission or discharge, assess need for psychotropic
medication or treatment, evaluate effectiveness of psychotropic medication, assess risk, forensic evaluations,
assess delirium, and form psychiatric diagnoses

o Appearance: perceived age, grooming, dress, and posture

o Behavior: gait, gestures, and movements
o Attitude: affable, apathetic, cooperative, defensive, distracted, evasive, hostile, guarded, oppositional
o Mood and Affect:
§ Mood: Patient’s report of his or her emotional status, including frequency and duration (subjective) →
common mood descriptors: anhedonia, angry, anxious, depressed, elation, euphoria, excited, labile
§ Affect: What you see and hear when interacting with patient (objective) → common affect descriptors:
normal, incongruent, constricted, flat, labile
o Speech: describe the manner of speech and not the content → rate, fluency, rhythm, volume, quality
o Thought/perceptual disturbances: delusions, hallucinations, illusions, ideas of reference, phobias, obsessions
§ Delusions: firmly held belief not based on reality
• Persecutory: others are deliberately trying to wrong, harm or conspire against another
• Grandiose: exaggerated sense of one’s own importance, power or significance
• Somatic: belief that medical problems exist
• Reference: belief that otherwise innocuous events or actions refer specifically to individual
• Control: belief that thoughts, feelings, impulses and actions are controlled by an external agency
• Erotomania: stranger or celebrity loves the person
• Guilt: believes they committed an unforgiveable deed
• Jealous: belief others are unfaithful
• Nihilistic: belief that self or part of self, others, or the world does not exist
• Religious: false belief one has an exaggerated link to God
o Abstract thinking: evaluate severity, fixedness, elaborateness, power to influence the patient, degree
o Hallucinations:
§ Auditory → common in psychosis
§ Visual → common in medical disorders
§ Tactile → touch, which is common in drug use/withdrawal
§ Gustatory → taste
§ Olfactory → smell, which is common in seizures
o Fund of Information and Knowledge:
§ A general level of intelligence can be approximated by the level of education achieved (although this is
not always accurate)
§ Speaking vocabulary is also a good estimate of intelligence
o Memory: can be assessed in 4 dimensions
§ Immediate memory → registration, retrieving what a person has just been told Registration
§ Recall memory → remembering and repeating 3 words from earlier in the MMSE
§ Recent memory → retrieving material from the past several minutes to days
§ Remote memory → recalling events from the distant past
o Judgement: the ability to handle social situations (weigh consequences), understand and adhere to reasonable
social norms
§ Good judgement → ability to assess, discern, and choose among various options in a situation
§ Impaired judgement → diminished ability to understand a situation correctly and to act appropriately
o Impulse control: asses their level of control during the interview and assess as part of the history
o Insight: the capacity to understand the presence of a problem, to think about it’s origin and how it might be solved
o Assessing Patient’s Strengths and Challenges:
Learning and Behavior Change:

• Learning is a change in behavior in response to an event or stimulus that achieves a desired outcome
o Learning is a fundamental operation of all behavior, from the basic cell to the complete organism
• Two major learning theories:
o Classical conditioning → the repeated pairing of a neutral stimulus with one that evokes an involuntary
response (unconditioned response) so that the neutral stimulus eventually comes to evoke the response (the
conditioned stimulus and conditioned response)
§ Definitions in classical conditioning:
• Learning is the association of things that takes place together in time → A.K.A pairing
• Discrimination → discrimination between two different stimuli
• Habituation → response decreases with additional exposures
• Sensitization → response increases with additional exposure
• Extinction → the conditioned response can be extinguished or cancelled out
• Extinction burst → when behavior increases just prior to extinction
• Spontaneous recovery → the extinguished response may seem to have entirely disappeared
but then spontaneously reappears at any point
§ Therapies based on classical conditioning:
• Exposure therapy (flooding or implosion) → uses flooding (exposure to the feared stimulus)
→ the patient remains in phobic situation until the anxiety response goes away (extinction
occurs)
• Systematic desensitization → gradual exposure (mental or physical) to feared stimulus paired
with relaxation
o Generate a hierarchy of low to high fearful stimuli
o Learn and practice relaxation
o Hierarchy of feared stimuli presented over time while patient relaxes, increase
exposure until relaxation is maintained in presence of most feared stimuli
o It works based on counter-conditioning → replacing one condition with another,
replacing anxiety with relaxation
• Aversive conditioning → stimulus changed to evoke avoidance rather than approach response
o Operant conditioning → learning occurs as a consequence of actions that produce punishments or rewards
→ often voluntary responses
§ Definitions in operant conditioning:
• Reinforcement → results in a behavior increase

c
 • Punishment → results in a behavior decrease
o A punished behavior may only be temporarily suppressed
o Punishment often conditions negative emotional responses and may lead to escape or
avoidance behaviors
o Punishment does not illustrate the correct behavior
o Severe punishment may cause physical/psychological harm
• Positive → something is added
• Negative → something is taken away

• Intrinsic and extrinsic motivation: goal is to make the new behavior the reward itself → if
behavior remains motivated by external reward, it is subject to extinction due to dependence
on reward → once behavior is motivated by personal meaning, it can withstand variation in
reward and be maintained
o Intrinsic → new behavior is itself rewarding
o Extrinsic → added positive reinforcement is the motive for behavior
§ Therapies in operant conditioning:
• Shaping → building a desired behavior through successive approximation
• Stimulus control → avoiding triggering stimuli in order to reduce the behavior
• Biofeedback → learning to control internal states through monitoring
• Fading → gradual reduction of reinforcement
• Modeling → learning by observing someone else
x
Mini-Mental Status Examination:

• Orientation to time: date, day, month, year, season

• Orientation to place: place, floor, city, state, country
• Orientation to person: patient stating their full name
• Orientation to situation: does the patient know why they are here
• Memory:
o Immediate memory
o Recall memory
o Recent memory Alzheimer's
o Remote memory
dihficulty
• Attention: reverse spelling of a word (WORLD) and serial 7’s
withsemantic
• Language: naming, repetition, comprehension, reading and writing memory
• Writing: ask the patient to write a sentence for you
• Visual-spatial skills: assess ability to perceive objects, construct drawing and copy → overlapping pentagons
• Level of consciousness: alert, drowsy, stuporous, comatose
Health Literacy:

• Health literacy is the degree to which individuals have the capacity to obtain, process and understand basic health
information and services needed to make appropriate health decisions → health literacy is a cognitive and social skill
that determines the motivation and ability of individuals to gain access to understand and use health-related
information → skills: reading and writing abilities, communication proficiencies, numerical computing and
comprehension, and critical decision making
• What is the average patient? Average Americans read at the 8th grade level → BUT most health education materials
are written at a 12th grade level or college level → even highly literate, well-educated adults report difficulty
understanding information provided to them by clinicians → Be alert to cues that your patient may not understand
you or be able to read the instructions

• What we expect of patients: understand the functions of the body, explain symptoms accurately, ask the right
questions, identify a fact versus a myth, be proficient in self-care, be accurate historians, learn complex information
and translate it into practice, calculate medication dosages, and understand forms and lab test results
o Expectation that patients are asked to complete forms and read information before and after the physician
encounter → among patients at the lowest levels of literacy, 80% NEVER use the internet to get health
information
o Identify fact versus myth → the internet requires several literacy skills → those that do access, do not always
have correct info
• Why are patients at risk for poor health literacy? Increasingly complex healthcare system, more medications, more
tests and procedures, growing self-care requirements, esoteric language, an aging population, and a more culturally
diverse patient population
• Longer hospitalizations
o Not only are patients with low health literacy twice as likely to be hospitalized, when they get to the hospital
they stay longer
§ This happens because patients do not understand treatment regimens and/or the important of
following them and they make medication errors → patients present at later stages of illness before
seeking help → and they use the emergency department more often
• Impact of low health literacy: ACCESS
o Selecting health care site
o Seeking preventative care
• Health literacy impact: Safety
o Accuracy of self-report → knowing the correct vocabulary to use for symptoms and medication use
o Informed consent
o Patients may be nervous when talking with professionals and not speak up and disclose much needed
information
• Health literacy impact: Quality:
o Patient satisfaction is important measure
o Patients who have trouble understanding their doctor’s instructions often report lower satisfaction with their
healthcare setting
• Who is at most risk for low health literacy? Elderly (65+), ethic and racial minorities, immigrants with limited
education, low socioeconomic status, and people with chronic disease
o At least 80% of elderly have at least one health issue
o 40% of elderly reported non-adherence to prescription treatment regimen
o 48% of seniors with low health literacy do not understand what “take your medicine every six hours meant”
o 100% of low literacy seniors did not understand Medicaid rights, written at 10th grade level
• Strategy: Recognize Red Flags
o Not following instructions for self-care, inability to follow medication instructions, difficulty filling out forms,
making excuses, perceived resistance, does not have any or few questions, frequently missed appointments,
non-adherence to medications, and inability to give accurate medical history
• Strategy: Assess during the interview
o Take a detailed social history and ask about education, involve other family is appropriate and consent is
obtained,
• Strategy: improve interpersonal interactions
o SLOW DOWN, convey an attitude of helpfulness/care/respect, use plain non-medical language, use
analogies and pictures DRAWN BY PHYSICIAN, repeat, focus on 1-3 key messages
• Strategy: use teach-back method
o Ask patient to demonstrate understanding → DO NOT ASK “Do you understand”
• Limited English Proficiency (LEP):
o Face a greater risk for poor communication during doctor-patient encounters
o 52 million US residents speak language other than English at home
o Office of Civil Rights in the Title VI guidance memorandum states that denial or delay of medical care for
LEP patients because of language barriers constitutes as a form of discrimination and requires that providers
must give adequate language assistance to LEP patients who have Medicaid or Medicare
o Recognize the need: your patient needs an interpreter if the patient or parent of the patient is LEP and you
are not fluent in the patient’s language
§ The GOLD standard is the fluent health care provider
§ 2nd best: professional live medical interpreter
§ 3rd best: 2 way video remote interpreters
§ 4th best: Telephonic interpretation services
§ Last: Ad hoc interpreter- emergency option only when no other option is available
o Meet briefly with an interpreter before patient encounter to discuss goals and ensure appropriate match →
speak in first person (do not say “tell her”) → address the patient directly and ask the interpreter to sit next
to or slightly behind the patient
§ Allow sentence by sentence interpretation
§ The discussion should be limited to no more than 3 major points
§ Attempts at humor are often lost in interpretation
§ Refrain from making side comments that the patient can hear in English
• WE DO NOT need to be firm for our patients to adhere to treatment plans → the patient-relationship is the most
important aspect for adherence and the more collaborative the interaction, the more the adherence increases
o Adherence assumes that the prescribing is appropriate and that the patient and provider agree on the treatment
plan → this agreement on the treatment plan is often called concordance, and is considered to be a separate
but related concept from adherence
§ Factors that increase adherence:
• Doctor patient relationship is the MOST IMPORTANT → doctor’s sensitivity to patient’s
health benefits and enthusiasm/time given
• Patient knowledge of how medicine/lifestyle change will help as well as knowledge of
understanding instructions
• External factors: doctor experience and older age, short waiting room time, and patient feels
ill or acute illness
§ Factors that decrease adherence:
• Relationship → patient perception that physician is cold and unapproachable and implicit bias
from health care providers
• Physicians failure to explain diagnosis or cause of symptoms in a language that the patient can
understand
• External factors: complex treatment schedule, increased behavioral changes, visual problems,
and chronic illness
o Compliance is when the patient follows instructions and takes medication on schedule, keeps appointments
and follows direction
o Non-adherence: little relationship between compliance and race, sex, religion, socioeconomic status, marital
status, intelligence and education
A 44 year-old male of Hispanic descent comes to the emergency department with
his 9 year-old son. He points to his throat and states "medicor." His son speaks
English and Spanish, informing you that his father began experiencing severe
pain 6 hours ago. Which initial action by the physician is the most appropriate?

A. Ask the son to explain more information about his father's current symptoms.
B. Request a professional interpreter to be present as patient is being examined.
C. Ask any surrounding nurses or staff if they can interpret for patient.
D. Use pictures and hand gestures to get more immediate information about
patient's symptoms.
E. Ask the son to contact a family member that can make decisions on the patient's
behalf.
A 65-year-old woman comes to the physician for follow-up accompanied by her
husband. Her medical problems include diabetes and poorly controlled
hypertension. Her medications include once-daily metformin and an ACE
inhibitor. At her last visit, the patient’s dose of ACE inhibitor was increased. At
today’s visit, her blood pressure remains elevated. Her husband says, “I told her
that she has to take her medications daily, but she thinks she is doing just fine. You
have to talk to her.” The patient admits that she does not like to take medication
every day and is not particularly concerned that her blood pressure is high. Which
of the following responses by the physician is the most appropriate to address this
patient’s non-adherence with her medication regimen?

x
A.
B.
How often to you skip your medication?
I understand it has been difficult; lets go over how to take the
medication together.”
C. Many patients find it difficult to take medication everyday; tell
me more about what makes it hard for you.
D.
x Would you feel more comfortable discussing medication without
your husband present?
x
E. Your blood pressure is elevated today; did you know it only
works when you take it every day?
x
F. Your husband is correct to be concerned.
 Death and Dying:

• Palliate: to ease pain without curing

o Palliative care is an approach that improves the quality of life of patients and their families facing the problems
associated with life-threatening illness, through the prevention and relief of suffering by means of early
identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial
and spiritual
o Nationally, 67% of US hospitals with 50 or more beds report staffing palliative care teams

Difference
between
palliativeand
hospice

• Hospice: when a cure is no longer possible, hospice recognized that a peaceful and comfortable death is an essential
goal of healthcare

• Kubler-Ross Stages of Death, Grief, and Loss: these stages are not sequential and they can be experienced in any
order know stagenamesanddescriptions
o Stage 1: Shock and Denial
§ Very common
§ Can look like a daze
§ Also can be in denial that anything is wrong
§ Allow time and space for patients to have emotional response
§ Do not try and get convince them out of this stage
o Stage 2: Anger
§ Can look like frustration, irritability, and anger
§ Commonly ask “why me?”
§ May be angry at God, family, and medical team
§ Recognize anger is not personal toward you
§ Being empathetic and non-defensive can help defuse patient’s anger and help them refocus on their
own feelings
o Stage 3: Bargaining
§ Attempts can be made to negotiate for a cure
§ Reinforce partnership
o Stage 4: Depression
o Stage 5: Acceptance
• The family is the unit of care
o Bereavement: experiencing the death of a loved one and other significant losses → bereaved persons have
higher morbidity and mortality rates for at least the first 6 months after loss
o Normal grief: usually resolved within 6-12 months after the death
§ Physical → chest tightness, heart palpitations, decreased energy, weight loss or gain, sleep
§ Psychological → emotional numbing, sadness, anger, guilt, anxiety
§ Cognitive → disbelief, confusion, low self-esteem

Bereavement

knowhow todifferentiatebereaveontfroma mooddisorder

Breaking Bad News:

• Bad news is any information which adversely and seriously affects and individual’s view of his or her future
• In North America, principles of informed consent, patient autonomy and case law have created clear ethical and legal
obligations to provide patients with as much information as they desire about their illness and treatment
o Physicians MAY NOT withhold medical information even if they suspect it will have a negative impact on
the patient
• Patient’s Bill of Rights:
o To receive considerate and respectful care
o Receive accurate information about their illness
o Informed consent for all treatment decisions
o Active participation in all decisions
o Transfer of all the above to legal surrogate if unable to make decisions
• Advance Directive: legal document that provides instructions/guidance regarding your preferences for medical care
if you are unable to make decisions yourself
• DNR: request to withhold CPR if patient’s heart stops or if they stop breathing
• SPIKES protocol:
shameofeachstepandtechniquesimplemented
o Step 1: Setting up the interview
o Step 2: Perception of the patient
o Step 3: Invitation
o Step 4: Knowledge
o Step 5: Emotions/Empathy
o Step 6: Summary/Strategy
Abuse:

• Demographics of Child Abuse

o More than 3 million cases of child abuse are reported each year, with 1 million cases being substantiated.
o More than 1400 children die from inflicted injuries annually, 45% of whom are younger than 12 months.
o An abused has ~50% chance of being abused again and has an increased risk of dying if the abuse is not
stopped after the first presentation.
o Physicians have the responsibility of recognizing abuse cases at first presentation to prevent significant
morbidity and mortality.
• Risk Factors for Child Maltreatment
o Child Factors:
§ Less than 1 year old
§ Behavior problems (hyperactive)
§ Medical fragility or illness
§ Developmentally delayed
§ Non-biologic relationship to the caretaker
§ Prematurity
o Caregiver Factors:
§ Criminal history
§ Inappropriate expectations of the child
§ Mental health history
§ Misconceptions about child care or child development
§ Substance abuse
o Family & Environmental Factors
§ Intimate partner violence in the home
§ Social isolation or lack of social support
§ High local unemployment rates and Poverty
• Defining Child Abuse
o The Child Abuse Prevention and Treatment Act (CAPTA) defines abuse as: “A recent act or failure to act
that results in death, serious physical or emotional harm, sexual abuse or exploitation, or imminent risk of
serious harm; involves a child; and is carried out by a parent or caregiver who is responsible for the child’s
welfare.”
• Role as the Physician
o Medically, each type of abuse is approached differently, but all require that the physician report suspicions to
appropriate authorities.
§ If possible, separate child from adult
§ Report to Child welfare agency
o In general physicians tend to over report by a 2:1 ratio
o Prefer that you oversensitive, in test questions if not sure respond as if you are sure.
• 4 Main Types of Child Abuse NEEDTOKNOW EVERYTHINGaboutdifferenttypesofabuse
o 1. Neglect
§ Failure to provide for a child’s basic physical, emotional, educational/cognitive, or medical needs.
§ Thus the four subtypes of neglect are:
• Physical neglect involves failure to provide adequate food, clothing, shelter, hygiene,
protection, or supervision.
• Emotional neglect involves the failure to provide love, security, affection, emotional support,
or psychological care when needed. Exposure to interpersonal violence may also be
considered a type of neglect.
• Educational or cognitive neglect involves lack of proper enrollment in school, lack of
supervision of school attendance, or failure to meet essential educational needs.
• Medical neglect is the delay in or refusal to see medical care, resulting in damage to the
child’s well-being.
§ Neglect is the most common type of child abuse and makes up ~60% of reported cases. It is the
most common cause of death in abused children.
§ Physician’s Role in Neglect Cases
• Well-child visits should include information about nutrition, safety, injury prevention,
developmental stages, dental and eye care recommendations, and educational needs.
• If neglect is suspected, the physician should obtain a full medical history, psychosocial
history, and a complete physical examination.
• If a diagnosis of neglect is unclear, the physician should arrange a home visit by a social
worker or home-nurse.
• Assure safety of child and contact Child Protective Services even when in doubt.
o 2. Emotional Abuse
§ Abuse that results in demonstrable harm (i.e., impaired psychological growth and development) of a
child.
§ Emotional abuse may be the most difficult form of abuse to recognize in a clinical practice.
§ Patterns of Behavior in Emotionally Abused Children
• Social withdrawal/isolation
• Excessive anger or aggression
• Eating disorders
• Failure to thrive
• Developmental delays
• Emotional disturbances (e.g., depression, anxiety, fearfulness, history of running away from
home)
§ Physicians Role in Emotional Abuse Cases
• If the episode of suspected emotional abuse is isolated, and there is no immediate danger to
the child, physicians should recommend family therapy, parenting classes/training, and other
supportive therapies for the child and family.
• If the emotional abuse is recurrent or there is possibility of imminent harm to the child,
contact Child Protective Services.
• In some states, exposure to Intimate Partner Violence in the home is considered by law to
be a form of emotional harm.
• Physicians should seek the advice of local experts to determine if children who witness IPV
should be referred to CPS.
 o 3. Physical Abuse:
§ Clinical Evaluation
• Physical abuse may be a part of the differential diagnosis for many injuries in children
o Gather a detailed, chronological history related to the injury.
o Does the caregiver’s explanation fit with the child’s injuries?
• Bruises, bites, burns, fractures, abdominal trauma, and head trauma are the most common
physical findings.
• Other suspicious injuries include posterior rib fractures; retinal hemorrhages; skull fractures
in infants; long bone fractures in children younger than two years; scapular, spinous process,
and sternal fractures, and cigarette burns.
• The diagnosis of abuse should be considered when there are injuries to multiple areas,
injuries in various stages of healing or suspicious injury patterns.
• Histories from caregivers should be obtained separately and as soon as possible. Careful
documentation is essential.
• Take photos of the injuries. When possible, a medical photographer or child abuse
investigative authority should take the pictures.
§ Physical Abuse of a Child: Clues in the Evaluation of Inflicted vs. Non-inflicted Trauma in Children
• Suspect inflicted trauma if the answer is yes to any of the following questions:
o Is there an unusual distribution or location of lesions?
o Is there a pattern of bruises or marks?
o Can a bleeding disorder or collagen disease be ruled out as a cause of lesions?
o If there is a bite or handprint bruise, is it adult size?
o If there is a burn, are the margins clearly demarcated with uniform depth of burn?
o If there is a burn, is there a stocking and glove distribution?
o Are there lesions of various healing stages or ages?
o Is the reported mechanism of injury inconsistent with the extent of trauma?

Category Abuse Signs

KNOWTHIS CHART
Neglect Lack of needed nutrition; Poor personal care (e.g. diaper rash, dirty hair)

Bruises Bruising in areas not likely to be injured during normal play, such as on the
buttocks or lower back
Bruising of soft issues which is not over bony prominences
Bruising of an infant (who is not yet mobile)
Belt or belt buckle shaped bruises

Burns Cigarette burns

Burns on hands, feet or buttocks caused by immersion in hot water

Fractures Fractures (e.g. skull, rib, spinal, clavicular) at different stages of healing
Spiral fractures caused by twisting of the limbs
“Bucket-handle” fractures (on the edge of bone between the metaphysis and epiphysis)
Other Signs Internal abdominal injuries (e.g., ruptured spleen)
Wrist rope burns caused by tying to a bed or chair
Injuries to the mouth caused by forced feeding
Petechiae (pinpoint hemorrhages on the skin) caused by excess pressure
“Shaken baby” syndrome, e.g. retinal (in 50-100% of cases) and brain injuries caused by shaking the
infant to stop him or her from crying.

Recommended Studies for Physical Abuse Evaluations

STUDY: INDICATION:
- Dilated, indirect ophthalmoscopy performed by an - To detect retinal hemorrhages in children younger
ophthalmologist than 2 years
- Head CT - To detect subarachnoid, subdural, or
- Laboratory evaluation: amylase, complete blood intraparenchymal injury
count, hepatic transaminases, lipase, partial - To detect genitourinary or abdominal trauma and to
thromboplastin time, prothrombin time, fecal ensure no underlying blood disorder
occult blood test, urinalysis, and urine toxicology - Suspected old or new fracture
- Skeletal survey radiography (i.e, of the spine,
extremities, skull)
o Sexual Abuse
o The employment, use, persuasion, inducement, enticement, or coercion of any child to engage in, or to
assist any other person to engage in, any sexual explicit conduct or simulation of such conduct for the
purpose of producing a visual depiction of such conduct; or the rape, molestation, prostitution, or other
form of sexual exploitation of children, or incest with children.
o 3 Types of Sexual Abuse
§ Non-touching sexual abuse
§ Touching sexual abuse
• Fondling
• Making a child touch an adult’s sexual organs
• Touching a child with their sexual organs
• Any penetration of the child’s vagina or anus by an object that doesn’t have a medical
purpose
• Oral-genital stimulation
o Sexual exploitation
§ Engaging a child for the purposes of prostitution
§ Using a child to film, photograph or model pornography
o Demographics
§ 150,000 to 200,000 of confirmed cases of sexual abuse per year.
§ 50% of cases are within the family
§ 60% of victims are females
§ Most victims are 9 to 12 years of age
§ 25% are younger than 8 years
§ Most likely Perpetrator:
• Stepfather
• Boyfriend of mother
• Uncles, older siblings
 Possible Signs of Abuse
Younger Children Prepuberty & Young Teens Older Teens
- Compulsive masturbation - Stealing - Suicide attempts
- Bed-wetting, soiling - Running away - Early marriage
- Excessive curiosity about sex - Starting fires - Running away
- Altered sleep patterns - Excessive bathing - Pregnancy
- Learning problems - Withdrawal & passivity - Substance abuse
- Separation anxiety - Sexual inference in artwork or - Getting in trouble with legal
- Becoming seductive essays system
- Overly compulsive behavior - Aggression toward peers
- Developing fears & phobias - Periods of deep depression
- Sexual acting out with peers - Falling grades
- Becoming nonverbal - Alcohol or drug abuse
- Symptoms of tension: stomach - Teaching others to masturbate
aches, skin disorders, etc.

Physical Indicators of Sexual Abuse

- Bruises or bleeding in external genitalia
- Complaints of pain or itching in genitalia
- Difficulty in sitting or walking
- Torn, stained or bloody underclothing
- Sexually transmitted diseases
- Pregnancy, especially in early adolescence

Other Indicators of Sexual Abuse

- Unusual knowledge of sex

o Example: Oral sex at a young age
- Excessive Dependency on Caregiver
- What about children and children?
o Normal at some ages to have same age ‘exploration’
o Age difference is important

Sexual Abuse Clinical Evaluations

- Less than 10% of substantiated child sexual abuse cases have physical findings on examination.
- Therefore, the history is the most important part of the sexual abuse evaluation.
- Documentation should include the child’s exact words.
- A physical examination should be done as soon as possible if a child with suspected maltreatment complains of
dysuria, anal or vaginal bleeding, vaginal discharge or pain on defecation.
- Examination under anesthesia should be considered in some cases.
- Specialized training programs are available for physicians who plan to perform these evaluations regularly.
Questioning the Child

- Begin with general, open-ended questions

- Allow the child to tell details of abuse scenario
- Progress to focused, non-leading questions
- Use language appropriate to child’s developmental level
- Use names rather than relationship words
- Avoid coercive questions
- Avoid jargon, legalese and technical words

Child Sexual Abuse History Interview Recommendations

- Explain to the child who you are and why you are there.
- Ask if the child knows why he or she is there.
- Use short simple sentences, simple tenses, and active verbs.
- Use concrete terms and proper names.
- Use direct questions.
- Verify the child’s statements.
- Rephrase questions if needed.
- Ask if the child understands the question.
- Offer the option of writing answers down or drawing the event.
- Interview the child out of the presence of the parent if possible.
- Do not be biased, leading, suggestive, or presumptive.
- Ask about medical history, medications, menstrual history, sexual history (this allows you to determine the language
and development of the child)
- Ask about symptoms (e.g., physical, emotional)
- Ask for a description of the event.
- Get clarification.
- Ask about the child’s concerns or fears.
Adult Sexual Assault

- Every 2 minutes, someone is sexually assaulted in the United States.

- 1 out of every 6 American women has been the victim of an attempted or completed rape in her lifetime.
- 1 out of every 33 American men has been the victim of an attempted or completed rape in his lifetime
o Now considered higher, 20%
o 1 out 6 unwanted sexual contact by age 16
- 12-34 are the highest risk years for sexual assault
- Girls ages 16-19 are 4 times more likely than the general population to be victims of rape, attempted rape, or sexual
assault
- Adolescents raped during their adolescent years were 13.7 times more likely to experience rape or attempted rape in
their first year of college

Sexual Assault: Populations at Risk

- Individuals with Intellectual Disabilities:

o 49% will experience at least 10 sexual assaults
o 4x more likely to be sexually assaulted
- Individuals with Disabilities:
o 50% of Deaf children
o Research very difficult to ascertain numbers for multiple reasons
o Women with disabilities are raped and abused at a rate at least twice that of the general population of
women.
o Among adults who are developmentally disabled, as many as 83% of the females and 32% of the males are
victims of sexual assault
- GLBT
o The National Coalition of Anti-Violence Programs reports that lesbian, gay, bisexual, and queer people were
three times more likely to report sexual violence and/or harassment compared to heterosexual people who
reported to NCAVP in 2010.
- Transgender
o Approximately 50% of transgender people experience sexual violence at some point in their lifetime
o One in ten transgender individuals have been sexually assaulted in a healthcare setting

How to react as a physician?

- Provide Immediate Emotional Support

o Ensure safety
o Provide empathy
o Be nonjudgmental
o Be gentle
o Avoid traumatizing
- Things you can say & do:
o This is not your fault.
o No one deserves to be treated this way.
o I’m sorry you’ve been hurt.
o Do you want to talk about it? (be careful of reliving)
§ Follow the patient’s lead
o Help is available to you.
o Bring in the experts! Refer to Rape Crisis Center if available.
Elder Abuse

- Approximately 450,000 non-institutionalized persons aged 60 and over are subject to abuse or neglect each year (US
Administration in Aging). About 80% of cases go unreported.
- 3 Categories of Abuse
o Physical Abuse
§ Willful infliction of physical pain/injury
• Hitting, slapping, shaking, striking with objects, physical/chemical restraints
o Sexual Abuse
§ Nonconsensual Sexual Contact
• Rape, unwanted touching, innuendos, sexual advances
o Psychological Abuse
§ Conduct resulting in mental/emotional anguish
• Threats to institutionalize or withdraw medication, nutrition, or hydration
o Financial or Material Exploitation
§ Misappropriating an older person’s assets for someone else’s benefit
• Theft/blackmail, coercion to change wills or other legal documents that counters victim’s
best interest
o Neglect (50% of cases)
§ Failure to provide goods/services necessary for maintaining health and avoiding harm/illness
• Active-Intentional: refusal to provide basic needs of hygiene, food, medication, physical
assistance (needed for safety)
• Passive-Unintentional: due to ignorance or inability of caretaker to provide needs.
- Barriers to Disclosing/Identifying
o Patients
§ Are socially isolated
§ Fears of being punished
§ Cognitive impairments
o Physicians
§ Underestimate the prevalence
§ Don’t feel confident in assessing nor have a plan for responding to the victim
§ Denial-reluctance to intervene, fear of angering family/patient
- Assessment
o Careful History
§ Try and observe both patient and caregiver together to observe relationship
• Notice anxiety in patient
• Overbearing attitude in caregiver
§ Interview patient privately
• Current health status
• Living arrangements
• Financial status
• Social support/emotional stressors
§ History of Alcohol and Drug abuse
§ Sexual History
- Physical Exam
o Poor physical care, psychosocial distress, bruising/burns, cognitive functioning, injuries due to secondary
fall, unexplained injuries, findings of sexual abuse
What to do if abuse is suspected?

- DOCUMENT ALL FINDINGS

o Written note
o Diagram of injuries
o Photographs if possible
o X-rays if applicable
o Labs (CBC, BUN, Creatinine, total protein, and albumin levels)
- Coordinate with community agencies is possible
o Trained interdisciplinary teams that can address abuse/neglect from social and medical perspective.

Common Characteristics of the Elderly Who are Abused or Neglected (Risk Factors)
1. Some degree of dementia or mental disorder
2. Poor health
3. > 75 yrs. old and Female
4. Low income
5. Physical dependence on others
6. Does not report the abuse, but instead says that he/she fell and injured him/herself
7. Is incontinent
8. History of domestic violence
9. Alcohol or other substance abuse

Common Characteristics of the Person Who May Abuse an Elderly Person

1. Substance abusing or dependent
2. Male
3. History of substance abuse or psychiatric problems
4. History of violent acts
5. Poverty level with social isolation
6. Financial dependence on the victim
7. The closest caregiver or family member (e.g. spouse, daughter, son or other relative with whom the person lives and
whom often supports the elder person financially) is most likely to abuse
8. Caregiver Burnout!!!!!
Signs of Elderly Physical Abuse

Category Abuse Signs

Neglect Lack of needed nutrition

Poor personal care (e.g., urine odor in incontinent person)
Lack of needed medication or health aids (e.g., eyeglasses, dentures)

Bruises Often bilateral and on the inner surface of the arms from being grabbed
Bruising of soft tissue which is not over bony prominences

Burns Cigarette burns

Other forms of burns (e.g., food to hot, bath too hot)

Fractures Fractures at different stages of healing

Spiral factures caused by twisting of limbs

Other Internal abdominal injuries (e.g., ruptured spleen)

Signs
Wrist rope burns caused by tying to a bed or chair
Injuries to the mouth caused by forced feeding
Evidence of depleted personal finances (their money was spent by the abuser & other family
members)

Intimate Partner Violence (PV)

- Intimate partner violence and emotional abuse are behaviors used by one person in a relationship to control the
other. Partners may be married or not married; heterosexual, gay, or lesbian; living together, separated or dating.
- Intimate partner violence falls under a broader umbrella of family violence which includes child abuse, elder abuse,
and intimate partner violence.
- Demographics of IPV
o Intimate partner violence is found in all racial, ethnic, religious, educational and socioeconomic
backgrounds.
o Approximately 1 out 4 women and nearly 1 in 7 men in the U.S. have experienced severe physical violence
by an intimate partner at some point in their lifetime, almost 50% of both genders endorsed psychological
aggression
o 35.6% of women and 28.5% of men in the United States have experienced rape, physical violence, or
stalking by an intimate partner at some point in their lifetime
o More than 1 in 4 gay men (26.0%), more than 1 in 3 bisexual men (37.3%), and nearly 3 in 10 heterosexual
men (29.0%) have experienced rape, physical violence, or stalking by an intimate partner at some point in
their lifetime
o 47% of men who beat their partners will do so three or more times a year.
o 52% of female murder victims are killed by a current or former partner
o Prevalence of Teen Dating Violence
§ 1 in 4 adolescents will experience some form of dating violence
§ 1 in 10 will experience severe physical dating violence
§ Higher rates observed in regional and at-risk samples
§ 38% (boys) to 57% (girls) of teens are victims of dating physical violence
 o Battered women may account for:
§ 22% - 35% of women seeking care for any reason in an ED
§ 19% - 30% of injured women seen in an ED
§ 14% of women seen ambulatory-care internal medicine clinics
§ 25% of women who attempt suicide
§ 25% of women utilizing a psychiatric emergency service
§ 23% of pregnant women seeking prenatal care
§ 45% - 59% of mothers of abused children
§ 58% of women over 30 years old who have been raped

Common Characteristics of Abusers in IPV

- Typically Male with a History of
o Substance Use
o Impulsivity
o Poor anger management
o Poor self-esteem
o Low tolerance with managing frustration

Common Characteristics of Victims in IPV

- Usually financially or emotionally dependent on Abuser

- Why do they return?
o Financially dependent
o Fear of Abuser retaliation (Abuse tends to increase when victim attempts to leave)
o No support system (isolation can be part of the abuse)
o No plan of escape
Physical Abuse in IPV

- Physical abuse is usually recurrent and escalates in both frequency and severity. It may include the following:
o Pushing, shoving, slapping, punching, kicking, choking
o Assault with a weapon
o Holding, tying down, or restraining
o Leaving someone in a dangerous place
o Refusing to help when someone is sick or injured

Emotional Abuse in IPV

- Emotional or psychological abuse may precede or accompany physical violence as a means of controlling through
fear and degradation. It may include the following:
o Threats of harm
o Physical and social isolation
o Extreme jealousy and possessiveness
o Deprivation
o Intimidation
o Degradation and humiliation
o Name-calling and constantly criticizing, insulting and belittling
o False accusations, blaming
o Ignoring, dismissing, or ridiculing
o Lying, breaking promises, destroying trust
o Driving fast and recklessly to frighten and intimidate

Sexual Abuse in IPV

- Sexual abuse in violent relationships is often the most difficult aspect of abuse for victims to discuss. It may include
any form of forced sex or sexual degradation, such as:
o Trying to make the person perform sexual acts against their will
o Pursuing sexual activity when the person is not fully conscious or is not asked or is afraid to say no
o Hurting a person physically during sex or assaulting their genitals, including use of objects or weapons intra-
vaginally, orally, or anally
o Coercing the person to have sex without protection against pregnancy or sexually transmissible diseases
o Criticizing and calling the person sexually degrading names

Physician’s Role in Evaluation IPV

- Because of isolation abused experiences

o Physician has a unique opportunity and responsibility to intervene.
- Physicians in all practice settings routinely see the consequences of violence and abuse, but often fail to
acknowledge the cause.
- If identified and addressed physicians can
o Provide referrals for shelter
o Refer for counseling and IPV advocacy
o Assist in transitioning to a safe environment.
Physician’s Limitations

- Unlike child and elder abuse cases, physicians treating intimate partner violence victims typically do not break
confidentiality or report the perpetrator to the authorities.
o Can vary from state to state-Dependent on type of injury
- Can only encourage and support victimized patients to take action and assist them in accessing resources available.

HITS Questions – Hurt, Insult, Threaten, Scream

- In the last year, how often did your partner:
o Hurt you physically?
o Insult or talk down to you?
o Threaten you with physical harm?
o Scream or curse at you?

Interviewing for IPV

- The prevalence of IPV justifies routine screening of all women seen in most medical settings.
- Questions about IPV should be asked in a nonjudgmental way.
o Are you in a relationship in which you have been physically hurt or threatened by your partner? Have you
ever been in such a relationship?
o Are you (have you ever been) in a relationship in which you felt you were treated badly? In what ways?
o Has your partner ever destroyed things that you cared about?
o Has your partner ever threatened or abused your children?
o Has your partner ever forced you to have sex when you didn’t want to? Does he ever force you to engage in
sex that makes you feel uncomfortable?
o We all fight at home. What happens when you and your partner fight or disagree?
o Do you ever feel afraid of your partner?
o Has your partner ever prevented you from leaving the house, seeing friends, getting a job, or continuing
your education?
o You mentioned that your partner uses drugs/alcohol. How does he act when he is drinking or on drugs? Is
he ever verbally or physically abusive?
o Do you have guns in your home? Has your partner ever threatened to use them when he was angry?
Diagnosis & Clinical Findings in IPV

- Injuries
o Contusions, abrasions, and minor lacerations, as well as fractures or sprains
o Injuries to the head, neck, chest, breasts, and abdomen
o Injuries during pregnancy
o Multiple sites of injury
o Repeated or chronic injuries
- Medical Findings
o Chronic pain, psychogenic pain, or pain due to diffuse trauma without visible evidence
o Physical symptoms related to stress,
o Chronic post-traumatic stress
o Disorder, other anxiety disorders, or
o Depression. Examples are:
§ Sleep and appetite disturbances
§ Fatigue, decreased concentration, sexual dysfunction
§ Chronic headaches
§ Abdominal and gastrointestinal complaints
§ Palpitations, dizziness, paresthesias, dyspnea
§ Atypical chest pain
o Gynecologic problems, frequent vaginal and urinary tract infections, dyspareunia, pelvic pain

Physician Intervention in IPV Cases

- Optimal care for victim in an abusive relationship depends on the physician’s working knowledge of community
resources that can provide safety, advocacy, and support.
- Even if a victim is not ready to leave the relationship or take other action, the physician’s recognition and validation
of the situation is important.
- Silence, disregard, or disinterest convey tacit approval or acceptance of intimate partner violence. In contrast,
recognition, acknowledgment, and concern confirm the seriousness of the problem and the need to solve it.
- Patient Safety
o It is imperative that the physician inquires about a battered patient’s safety before he or she leaves the
medical setting. The severity of current or past injury is not an accurate predictor of future violence; and
many victims minimize the danger they face. After assessing the situation, plans for the patient’s safety
should be discussed before he or she leaves the physician’ s office. Various options should be considered:
§ Does the patient have friends and family with whom he or she can stay?
§ Does the patient want immediate access to a shelter?
§ If none is available, can he or she be admitted to the hospital?
§ If the patient doesn’t need immediate access to a shelter, give him or her written information about
shelters and other resources if it is safe to do so.
§ Does the patient need immediate medical or psychiatric intervention?
§ Does the patient want immediate access to counseling to help him or her deal with the stress caused
by the abuse?
§ Does the patient want to return to his or her partner, with a follow-up appointment at a later date?
§ Does the patient need referrals to local domestic violence organizations?
A 5-year-old is brought to the emergency by her parents because of
chest and abdominal pain. Physical examination shows multiple
bruises on the abdomen and thorax in different stages of healing.
The physician notes the appearance of bruising on the child’s
forearms. An abdominal ultrasound is unremarkable. A chest x-ray
shows hairline fractures of the two ribs as well as evidence of
previously healed fractures. The parents say that they do not know
how she developed the bruises or fractures. Each time the physician
asks the child a question, she looks at her parents before she
answers and then after to make sure they approve her response.
Which of the following is the most appropriate next step?
A. Call the police immediately
B. Detain the parents
C. Hospitalize the child fro
further studies
D. Schedule counseling for the
parents and child
E. Separate the child from the
parents.
Patient is a 19 year-old female that was abused by her uncle at the ages of 9-
10. Which of the following accurately describes her future risk?

A. Patient will have a decreased

risk of being a repeat victim
of abuse or violence.
B. Patient will have a decreased
risk of perpetrating abuse or
violence toward others.
C. Patient has an increased risk
of depression, suicide and
substance abuse disorders
D. She will be less likely to
utilize medical services.
E. She will have a higher rate of
health-promoting behaviors
than her peers
A 45 year old woman comes to see her physician while 8 months
pregnant. The exam reveals bruises around her vagina and inner
thighs. When asked, patient reported that her husband got “very
forceful” when he was drinking last night. What is the most
appropriate physician response?

A. “Would you like some

information on Alcohol
Rehabilitation for your
husband?”
B. “Why do you think your
husband was forceful?”
C. “Do you feel it is safe for you
to return home?”
D. “I must contact the police and
tell them your baby is in
danger.”
E. “Has this happened before?”
A 34-year old woman is brought to the emergency room by her husband because a of a
persistent cough, nausea and difficulty breathing for the past four days. You also notice bruising
under her armpits. The couple presents as very religious and the woman was reported to have
deferred to her husband during the registration process and refused physical contact (i.e.
handshakes) with male nursing staff. When the patient speaks, the husband immediately
introduces himself and reports the patient’s medical history. Looking directly at the physician,
he says, “What can be done to help my wife”? After providing a general response, the physician
asks the wife how she is feeling. The wife does not answer an appears detached and avoids all
eye contact with the physician. Which of the following is the most appropriate next step?

A. Ask a female nurse to life the patient’s clothing so the physician can listen to
her lungs
B. Ask the husband to wait outside while the physician obtains a complete
history and examines the patient in private
C. As the patient directly to describe her symptoms.
D. Ask the patient if she wishes to have her husband present during the
examination.
E. Tell the husband that the best information comes directly from the patient and
question the patient directly about her safety in the home.
 Understand differentiatecyclothymiaanddysthymiafromotherdisorders

Cyclothymic Disorder Diagnosis

A. For at least 2 years, the presence of numerous periods with hypomanic
symptoms that do not meet criteria for hypomania and numerous
periods with depressive symptoms that do not meet criteria for a
Major Depressive Episode
◦ Note: In children and adolescents the duration must be at least 1
year
B. During the above 2 year period the person has the symptoms occur at
least half the time.
C. Criteria for Major Depressive, Manic, or Hypomanic Episode have
never been met.
Cyclothymic Disorder
Usually occurs in late adolescence and early adulthood

Insidious onset and persistent course

Lifetime prevalence of Cyclothymic Disorder is low (0.4-

1%)

This diagnosis is equally common in males and females,

females may be more likely to present for treatment
Persistent Depressive Disorder
(Formerly known as Dysthymia)
 Persistent Depressive Disorder Diagnosis

A. Depressed mood most of the day, more days than not, for at
least 2 years

B. Presence of 2 or more of the following (while depressed):

1. Poor appetite or overeating
2. Insomnia or hypersomnia
3. Low energy or fatigue
4. Low self-esteem
5. Poor concentration, difficulty making decisions
6. Feelings of hopelessness
 Persistent Depressive Disorder Diagnosis

* During the 2 year period, never been without criteria A and B for more
than two months.

* There has never been a manic, hypomanic, or mixed episode

* The disturbance does not occur exclusively during the course of a

chronic Psychotic Disorder such as Schizophrenia or Delusional Disorder

* The symptoms are not due to a general medical condition, the direct
physiological effects of a substance, or another psychological disorder

* The symptoms cause distress or impairment in one or more areas of

functioning

and
 Symptomsofdepressed manicand hypomaniaepisodes

Review of Major Depressive Episode Criteria

Five or more for the same 2 week period
1. Depressed mood most of the day, nearly every day
2. Diminished interest in almost all activities - Anhedonia
3. Change in appetite
4. Insomnia or hypersomnia nearly every day
5. Psychomotor agitation or retardation (daily, observable by
others)
6. Fatigue or loss of energy
7. Feelings of worthlessness or excessive, inappropriate guilt
8. Diminished ability to think or concentrate, indecisiveness
9. Recurrent thoughts of death, suicidal ideation without plan,
suicide attempt or active plan
 zyeds
z weeks
2
xx
Empirically-Validated
Psychotherapeutic Approaches

Cognitive Behavioral Therapy: Helpful in identifying early

warning signs of relapse, help to manage stress, learn
alternative coping strategies
Interpersonal and Social Rhythm Theory: teaches patients
to regulate social habits, develop routines, sleep patterns,
handle daily stress. Wellness Recovery Action Plan (Mary
Ellen Copeland)

Patients who use psychotherapy show a reduced risk of

relapse (especially for the depressive episodes)
 Major Depressive Disorder
with Seasonal Pattern
Now a specifier, not a diagnosis
◦ Usually during the winter months (low sunlight)
◦ Melatonin metabolism disruption/abnormalities
◦ Usually includes
- Increased sleep and appetite
- Decreased energy

Treatment
◦ Full Spectrum Light Therapy
◦ SSRI’s during winter months
Premenstrual Dysphoric Disorder Treatment

Good nutrition
◦ Limited salt, sugar, caffeine and alcohol
Exercise
◦ Seems to improve mood
Pain relievers
Medication
◦ SSRI’s
◦ Birth Control can help control severity
 Psychopharmacology Treatment For
Depressive Disorders

Tricyclics (TCA’s) Monoamine Oxidase Inhibitor

◦ amitriptyline (MAOI)
◦ nortriptyline ◦ May try after failed SSRI and
SNRI
◦ doxepin
◦ imipramine
◦ desipramine Selective Serotonin Reuptake
Inhibitors (SSRI)
◦ fluoxetine
Dual NE/5HT Reuptake Inhibitors
(SNRI) ◦ sertraline
◦ Venlafaxine ◦ paroxetine
◦ desvenlafaxine ◦ citalopram
◦ duloxetine ◦ escitalopram
Psychopharmacology – 1st line in primary care

Medication—which one to choose?

- Did one work before?
- Did one work for family member?
- Choose via side-effect profile
◦ Ex. Mirtazipine to target insomnia
- 1/3 get better, 1/3 get worse, and 1/3 stay the same
Maximize to dose, then switch if needed – trial
should be at least 6 months if possible
Medication therapy should be continued for at least
6-months or more to help prevent relapse

“Start low, Go slow”

 Psychotherapy Treatment for
Depressive Disorder

Psychotherapy
◦ Cognitive Behavioral Therapy (CBT)
◦ Interpersonal
◦ Increase pleasurable activity and social interaction
◦ Physical activity and exercise

Research shows the best way to treat depression is with a

combination of pharmacotherapy and psychotherapy
◦ Psychotherapy more beneficial for mild to moderate than
pharmacology treatment
 Diagnoseeachanxiety
disorder
byspecificsymptoms diagnosesandcharacteristics of
each

Essential feature: symptoms in response to

an identifiable stressor

o Symptoms develop within three months after

onset of stressor(s) and are out of proportion to
Adjustment the severity or intensity of the stressor
Disorder
o Clinical significance indicated by marked
distress or significant impairment in social or
occupational functioning beyond what would be
expected in response to stressor

o The stress-related disturbance does not meet

criteria for another disorder or exacerbation of a
pre-existing condition
 Adjustment Disorders

◦ Diagnosis does not apply to Bereavement

◦ By definition must resolve within 6 months of the

termination of the stressor

◦ May be continued if stressor is chronic (disabling medical

condition) or has enduring consequences
(financial/emotional problems stemming from divorce)
 Descriptors which best characterize the predominant
symptoms:

1. With Depressed Mood – tearfulness, depressed mood,

hopelessness
2. With Anxiety – nervousness, worry, agitation. In
children can be fears of separation from major
attachment figures
3. With Mixed Anxiety and Depressed Mood –
Adjustment combination of depression and anxiety
Disorder 4. With Disturbance of Conduct – Behavior in which
Subtypes there is a violation of rights of others or age
appropriate social norms (truancy, reckless driving,
fighting, vandalism, defaulting on legal obligations)
5. With Mixed Disturbance of Emotions and Conduct –
predominant symptoms of depression and/or anxiety
with disturbance of conduct
6. Unspecified – maladaptive reactions that do not fit
other categories (e.g., physical complaints, social
withdrawal, or work/academic inhibition)
 Adjustment Disorder - Specifiers

Acute – Persistence of symptoms for less than 6 months

Chronic – Persistence of symptoms of more than 6 months.

Applies when the symptoms are in response to chronic
stressor or stressor that has enduring consequences

Note: Adjustment Disorder can be coded as a primary or a

secondary diagnosis
 Anxiety Disorders

Most prevalent psychiatric condition

◦ Affects 40 million adults in the United States age 18+

◦ Approximately 18% of the population

Characterized by excessive or irrational fear and worry that

interferes with day-to-day functioning

Affects women nearly twice as much as men

 Anxiety Disorders
Separation Anxiety
Selective Mutism
Specific Phobias
Social Anxiety
Panic Disorder (and Panic Attack Specifier)
Agoraphobia
Generalized Anxiety Disorder
Substance/Medication-induced Anxiety Disorder
Anxiety due to Medical Condition
Other Specified Anxiety Disorder
Unspecified Anxiety Disorder
 DistinguishGADfromotheranxietydisorders

Generalized Anxiety Disorder (GAD):

Diagnosis
Excessive anxiety and worry about numerous aspects of daily life
Difficult to control the worry
Anxiety associated with 3 or more (in children just 1+):
◦ Easily fatigued
◦ Difficulty concentrating or mind ‘going blank’
◦ Irritability
◦ Sleep Disturbance
◦ Muscle tension
◦ Restlessness/keyed up
Anxiety causes significant distress or impairment
Not attributed to other medical/substance use/mental disorder
Occurring more days than not for at least 6 months
 Social Anxiety Disorder:
Diagnosis

Strong, persisting fear of situations where one is exposed to

unfamiliar people or possible scrutiny of others

•Fear that one will act (or show anxiety) in a way that is
humiliating or embarrassing
•Leads to avoiding situations or handling them with such
distress that it interferes significantly with life
•Fear/Anxiety out of proportion to the actual threat
•Fear/Anxiety lasts 6 months or longer
 Separation Anxiety Disorder:
Diagnosis
Anxiety concerning separation from those to whom the individual is attached as
evidenced by at least 3 of following:

◦ Recurrent/excessive distress when anticipating or experiencing separation

from home/major attachment figures
◦ Persistent worry about losing this figure (illness, death, etc.)
◦ Persistent/excessive worry about untoward events causing separation
(being kidnapped, accident, etc.)
◦ Reluctance or refusal to go out, be away from home, go to school/work for
fear of separation
◦ Persistent/excessive fear about being alone
◦ Persistent/excessive reluctance to sleep without figure
◦ Repeated nightmares involving theme of separation
◦ Complaints of physical symptoms when separated from figure
 Separation Anxiety Disorder

For diagnosis:
Children: Min 4 weeks Adults: Min 6 months

Lifetime prevalence of 1-2%

◦ Children have increased risk for suicide

Treatment
◦ If earlier treatment is initiated - better outcome
◦ Cognitive Behavioral Therapy is best treatment choice
and family therapy if needed
 Medicaland psychologicaltreatmentforanxietydisorders

Adjustment Disorder: Treatment

First line should be psychotherapy to address

symptoms and discuss alternative ways of
‘adjusting’ to stressor

Medications can be given for symptoms if

needed
 Generalized Anxiety Disorder:
Treatment

•Psychotherapy
• Behavioral (relaxation training, biofeedback)
• CBT (identifying triggers, core beliefs)
• Acceptance and Commitment Therapy (ACT)

•Pharmacotherapy
• SSRIs, SNRI’s, Buspirone, Venlafaxine, Benzodiazepines (with caution, longer
½ life)
• Also TCAs, antihistamines (vistaril), B-blockers

Most effective: combination of pharmacotherapy & psychotherapy

 Panic Disorder:
Treatment

Medications include SSRIs (70-80% success), tricyclic antidepressants,

benzodiazepines (with caution), propranolol

Cognitive Behavioral Therapy can give information to the patient about

what a panic attack is, its triggers, and effects, addressing false beliefs and
the misinterpretation of body sensations

◦ Behavioral techniques-relaxation training, respiratory training and

desensitization

Preferred Treatment = Combination of Psychotherapy + Medication

 Specific Phobias:
Treatment
Medications not really helpful
Behavior therapy has been found to be most effective:

◦ Systematic Desensitization
◦ Gradual process of exposing patient

◦ Exposure/ Flooding therapy

◦ Desensitization in vivo or using imagery

Hypnosis/self-hypnosis
Cognitive approaches help decrease irrational beliefs
 featuresand how
theyfit into a > 4 OF THE FOLLOWING SYMPTOMS:
diagnosis
r
Palpitations, pounding heart, accelerated heart
rate
Sweating
Trembling/shaking
Sensations of shortness of breath/smothering
What is a Feelings of choking

Panic Chest pain or discomfort

Nausea or abdominal distress
Attack? Feeling dizzy/unsteady/faint
Chills/heat sensations
Paresthesias = pins/needles, unusual nerve
sensations
Derealization = feeling as if things are not real
Fear of losing control/ “going crazy”
Fear of dying
 Panic Attack

•Surge of intense fear/discomfort that peaks within minutes

•Does not last long

• Usually 10-30 min and rarely past 1 hour

•For many, the first attack leads to an ER visit

 Panic Attacks
leading to a Panic Disorder

Diagnosis of a Panic Disorder requires at least one

panic attack followed by one month or more of at
least:

- Persistent concern about further attacks

- On-going worry about consequences of the attack(s)
- Change in behavior as a result of the attack(s)
 Panic Disorder:
Course & Prognosis

Chronic disorder with variable course

Excessive intakes of caffeine and nicotine may exacerbate symptoms
40-80% also have depressive symptoms
Increased risk of suicide
20-40% comorbid with substance dependence
Good premorbid functioning and less severe symptoms have
better prognosis
 knowthetypesofspecificphobias

Specific Phobia Types

Animal
Natural Environment (storms, heights, water)
Blood-Injection-Injury
◦ Fear of blood
◦ Fear of injections and transfusions
◦ Fear of other medical care
◦ Fear of injury

Situational (airplanes, elevators, enclosed spaces)

Other (clowns, etc.)
 OCDand OCPD
OCD Diagnosis:
Occurrence of obsessions, compulsions or both

Recurrent obsessions
• Intrusive thoughts, urges, feelings, ideas
• Failed attempts to ignore or suppress
Recurrent compulsions
• Behaviors (e.g., counting, checking, avoiding)
• Conscious, standardized, recurrent
• Feels driven to perform; done rigidly
• Excessive or not connected in real life to the problem
• Done to relieve anxiety associated with obsessions
Time Consuming

• > 1 hour/day; interferes with normal routine

• Causes marked distress or impairment in social,
occupational, or other areas of functioning

Not attributable to a substance, or other medical condition,

or other mental disorder

Specify:
• Degree of insight (good/fair/poor)
• Absent of insight/delusional beliefs
• Tic-related