Major rule-outs are mood disorders, personality change due to a general medical condition, and adjustment disorders. Individuals are mistrustful and suspicious of the motivations and actions of others and are often secretive and isolated.
They are emotionally cold and odd. A year-old man living in a condominium complex constantly accuses his neighbors of plotting to avoid payment of their share of maintenance. He writes angry letters to other owners and has initiated several lawsuits. He lives alone and does not socialize. Schizoid PD: Detachment and restricted emotionality. Individuals are emotionally distant. They are disinterested in others and indifferent to praise or criticism. Associated features include social drifting and dysphoria.
A year-old man lives alone and works nights as a security guard. He ignores invitations from coworkers to socialize and has no outside interests.
Schizotypal PD: Discomfort with social relationships; thought distortion; eccentricity. Individuals are socially isolated and uncomfortable with others.
Unlike Schizoid PD, they have peculiar patterns of thinking, including ideas of reference and persecution, odd preoccupations, and odd speech and affect. DSM- 5 includes this PD in both psychotic disorders and personality disorders. A year-old man is completely preoccupied with the study and the brewing of herbal teas.
He associates many peculiar powers with such infusions and says that plants bring him extra luck. He spends all of his time alone, often taking solitary walks in the wilderness for days at a time, collecting plants for teas.
At times he believes that songs on the radio are about his life. Cluster B Histrionic PD. Usually characterized by colorful, exaggerated behavior and excitable, shallow expression of emotions; uses physical appearance to draw attention to self; sexually seductive; and is uncomfortable in situations where he or she is not the center of attention.
When the doctor refuses to do so, she becomes upset. Borderline PD. Usually characterized by an unstable affect, mood swings, marked impulsivity, unstable relationships, recurrent suicidal behaviors, chronic feelings of emptiness or boredom, identity disturbance, and inappropriate anger. If stressed, may become psychotic. Main defense mechanism is splitting. A year-old nurse was recently admitted after reporting auditory hallucinations, which have occurred during the last few days.
She reports marriage difficulties and believes her husband is to blame for the problem. She has several scars on her wrists and has a history of substance abuse. Antisocial PD. Usually characterized by continuous antisocial or criminal acts, inability to conform to social rules, impulsivity, disregard for the rights of others, aggressiveness, lack of remorse, and deceitfulness.
These have occurred since the age of 15, and the individual is at least 18 years of age. He has had numerous problems with the law, which started at an early age when he was sent to a juvenile detention center for his behavior at both home and school.
He lacks remorse for setting the fire and expresses a desire that his mother would have died in the fire. Narcissistic PD. Usually characterized by a sense of self-importance, grandiosity, and preoccupation with fantasies of success. This person believes he is special, requires excessive admiration, reacts with rage when criticized, lacks empathy, is envious of others, and is interpersonally exploitative.
A famous actor is outraged when a director questions his acting abilities during rehearsal for a play. The actor responds by walking off the stage and not returning to the stage unless the director apologizes publicly for her behavior.
Cluster C Avoidant PD. Individuals have social inhibition, feelings of inadequacy, and hypersensitivity to criticism. They shy away from work or social relationships because of fears of rejection that are based on feelings of inadequacy. They feel lonely and substandard and are preoccupied with rejection. A year-old man dreads an upcoming company holiday party because he believes that he is incapable of engaging in social conversation or dancing.
He believes that he will become an object of pity or ridicule if he attempts such things. He anticipates yet another lonely holiday. Dependent PD: Submissive and clinging behavior related to a need to be taken care of.
Individuals are consumed with the need to be taken care of. They have clinging behavior and worry unrealistically about abandonment.
They feel inadequate and helpless and avoid disagreements with others. They usually focus dependency on a family member or spouse and desperately seek a substitute should this person become unavailable. Associated features include self-doubt, excessive humility, poor independent functioning, mood disorders, anxiety disorders, adjustment disorder, and other PDs. A year-old man is brought into the emergency room after sustaining severe rectal lacerations during a sadistic sexual episode with his partner.
Obsessive-Compulsive PD. Individuals are preoccupied with orderliness, perfectionism, and control. They are often consumed by the details of everything and lose their sense of overall goals. They are strict and perfectionistic, overconscientious, and inflexible. They may be obsessed with work and productivity and are hesitant to delegate tasks to others. Other traits include being miserly and unable to give up possessions.
Associated features include indecisiveness, dysphoria, anger, social inhibition, and difficult interpersonal relationships. A year-old woman seeks psychotherapy as a result of an impending divorce. She states that her demands to keep the house spotless, to maintain an extremely detailed and fixed work and recreational schedule, and to observe rigid dietary habits have driven her spouse away.
Normal Sleep and Sleep Disorders Learning Objectives Identify the normal sleep cycles Describe EEG, ENG, and physiologic phenomenon associated with each stage of sleep Categorize different sleep disorders and describe what is known about their causes. There are numerous differences between them. The brain is inactive while the body is active. NREM is made up of 4 stages. REM REM is a stage of sleep characterized by aroused EEG patterns, sexual arousal, saccadic eye movements, generalized muscular atony except middle-ear and eye muscles , and dreams.
The brain is active and the body is inactive. Sleep Facts Table I Also called slow wave or delta sleep Stages 3 and 4 Hardest to arouse Tends to vanish in the elderly. Sleep Latency. The time needed before you actually fall asleep. Typically less than 15 minutes in most individuals; however, may be abnormal in many disorders, such as insomnia, etc.
REM Latency. The period lasting from the moment you fall asleep to the first REM period. Lasts approximately 90 minutes in most individuals.
However, several disorders will shorten REM latency; these disorders include depression and narcolepsy. Total sleep time decreases. REM percentage decreases. Stages 3 and 4 tend to vanish. Serotonin: increased during sleep; initiates sleep Acetylcholine: increased during sleep; linked to REM sleep Norepinephrine: decreased during sleep; linked to REM sleep Dopamine: increased toward end of sleep; linked to arousal and wakefulness.
Human Sexuality Learning Objectives Present epidemiologic information about masturbation and homosexuality List the types of sexual dysfunction and differentiating factors Describe paraphilic disorder and gender dysphoria. Psychopharmacology Learning Objectives Describe the classes of drug, mechanism of action, and common adverse effects of typical antipsychotic, atypical antipsychotic, antidepressant, mood-stabilizing, and anxiolytic medications Describe the indications and procedural steps for electroconvulsive therapy.
Antipsychotic Medication Antipsychotic medications APMs are used to treat manifestations of psychosis and other psychiatric disorders. The precise mechanism of action is unknown; however, APMs block several populations of dopamine D2, D4 receptors in the brain. The newer APMs also block some serotonin receptors 5HT , a property that may be associated with increased efficacy.
APMs also variably block central and peripheral cholinergic, histaminic, and alpha-adrenergic receptors. Typical: work mostly on dopamine receptors, treat the positive symptoms hallucinations and delusions and have many side effects haloperidol, fluphenazine, chlorpromazine, etc. Atypical: work mostly on dopamine and serotonin receptors, treat both positive and negative symptoms flat affect, poor grooming, social withdrawal, anhedonia, etc , and have fewer side effects; always used as first-line agents risperidone, olanzapine, etc.
Hypotension: effect due to alpha-adrenergic blockade and most common with low-potency APMs. Anticholinergic Symptoms: dry mouth, blurred vision, urinary hesitancy, constipation, bradycardia, confusion, and delirium. Other Effects: cardiac conduction abnormalities especially with thioridazine , agranulocytosis with clozapine. Treatment: anticholinergics, such as benztropine, diphenhydramine, or trihexyphenidyl Can occur within hours after treatment.
Tardive Dyskinesia TD. Characterized by choreoathetosis and other involuntary movements Movements often occur first in the tongue or fingers and later involve the trunk. Patients who take high doses of older antipsychotic medication for long periods of time are at highest risk, and movements gradually worsen with continued use. Treatment: Use newer antipsychotic medications. Seen more frequently in elderly females Can occur after 3—6 months after treatment. The primary adverse effect of antipsychotic medication use is neuroleptic malignant syndrome.
It is a fairly rare and potentially life-threatening condition characterized by muscular rigidity, hyperthermia, autonomic instability, and delirium. CPK will be elevated. Usually associated with high dosages of high-potency antipsychotic medication. Treatment: Immediate discontinuation of the medication and physiologic supportive measures; dantrolene or bromocriptine may be used.
Recent suicide attempt Complaints of suicidal thoughts Admission of suicidal thoughts upon questioning Demonstration of possible suicidal behavior.
Psychotherapies Learning Objectives Describe and compare the major forms of psychotherapy and behavioral therapy used in practice today. Resolution 1. Psychologically 1. Psychoanalysis week of neurosis minded for years.
Focus on 1. Intact reality week 1. Insight interpersonal testing, capacity for oriented goals for insight months to years. Support 1. Days 1. Healthy patients to 1. Those with 1. Modify maladaptive learned 1. Time 1. Behavioral behaviors or behavior limited psychophysiologic patterns disorders. Alleviation of 1. Groups target 1. Group 1. Change 1.
Depressive 1. Epidemiology Learning Objectives Define incidence, prevalence, specific rates, adjusted rates, and other statistical measures, as they relate to morbidity and mortality Perform survival analysis including accounting for potential life lost Describe the types of prevention Show how prevalence, sensitivity, and specificity relate to the value of screening tests Answer questions about study design and bias in research.
Overview Epidemiology is the study of the distribution and determinants of health-related states within a population. It refers to the patterns of disease and the factors which influence those patterns. Endemic: The usual, expected rate of disease over time; the disease is maintained without much variation within a region.
Epidemic: Occurrence of disease in excess of the expected rate; usually presents in a larger geographic span than endemics epidemiology is the study of epidemics. Pandemic: worldwide epidemic. Incubation period is the period of time from the point of infection to the onset of clinical illness. Figure II Efficacy: performance of an intervention under optimal conditions, e. Biostatistics Learning Objectives List the basic principles of probability and describe the connection to statistics Demonstrate how to calculate mode, mean, median, standard error, and standard deviation, and describe how they differ Describe the purpose of inferential statistical tests, such as student T test, chi-square, and analysis of variance Select an appropriate statistical test for a set of data to be analyzed.
Probability Independent events : the occurrence of one event does not affect the occurrence of another.
For instance, the chance of a child being born with brown eyes is 0. The eye color of the first-born child does not affect the eye color of the second-born. Calculate the probability of multiple independent events occurring by multiplying each individual probability together. For instance, the probability of having one child with brown eyes and one child with blue eyes is 0. Nonindependent events : the occurrence of one event affects the occurrence of another.
For instance, a box has 5 white and 5 black balls inside. When picking the first ball, the probability of white is 0. Calculate the probability of multiple nonindependent events by multiplying each new probability, given that each previous event has occurred.
Mutually exclusive events : the occurrence of one event precludes the occurrence of another. For instance, if a coin flip lands heads, it cannot land tails. Determine the combined probability of mutually exclusive events by addition. For instance, the probability of a coin flip landing heads or tails is 0. If events are not mutually exclusive, determine the combined probability chance of either occurring of two events by adding the two individual probabilities together and subtracting their product.
Therefore, the chance of meeting someone who is diabetic or obese is 0. Combine probabilities for mutually exclusive events by addition. Mutually exclusive means that the occurrence of one event precludes the occurrence of the other i. If a coin lands heads, it cannot be tails; the two are mutually exclusive. So if a coin is flipped, the chance that it will be either heads or tails is 0.
If 2 events are not mutually exclusive, the combination of probabilities is accomplished by adding the two together and subtracting out the multiplied probabilities. Ethics Learning Objectives Identify some important Supreme Court cases related to medical ethics, and explain their significance Distinguish between the ethical and legal principles, and explain how they affect medical practice.
In the Quinlan case, Karen Ann was in a persistent vegetative state, being kept alive only by life support. Substituted judgment begins with the premise that decisions belong to the competent patient by virtue of the rights of autonomy and privacy. In legal terms, the patient has the right to decide but is incompetent to do so. Therefore, the decision is made for the patient on the basis of the best estimate of his or her subjective wishes. The New York Court of Appeals, in its decision of Eichner vs Dillon, held that trying to determine what a never-competent patient would have decided is practically impossible.
Obviously, it is difficult to ascertain the actual subjective wishes of incompetents. Therefore, if the patient has always been incompetent, or no one knows the patient well enough to render substituted judgment, the use of substituted judgment standard is questionable, at best.
Under these circumstances, decisions are made for the patient using the best interest standard. Note here the issue of who makes the decision is less important. All persons applying the best-interest standard should come to the same conclusions. As a general rule, parents cannot withhold life- or limb-saving treatment from their children.
Yet, in this exceptional case they did. Baby Boy Doe was born with Down syndrome trisomy 21 and with a tracheoesophageal fistula. Infant Doe died at 6 days of age, as Indiana authorities were seeking intervention from the U. Supreme Court. This case is simply an application of the best-interest standard. The court agreed with the parents that the burdens of treatment far outweighed any expected benefits. Because the mother gets to decide, even in the face of threats to the fetus, by extension, all patients get to decide about their own bodies and the health care they receive.
In the United States, the locus for decision-making about health care resides with the patient, not the physician. Note that courts have held that a pregnant woman has the right to refuse care e. A student visiting a counselor at a counseling center in California states that he is going to kill someone. When he leaves, the counselor is concerned enough to call the police but takes no further action. The student subsequently kills the person he threatened.
The court found the counselor and the center liable because they did not go far enough to warn and protect the potential victim. The counselor should have called the police and then should also have tried in every way possible to notify the potential victim of the potential danger. In similar situations, first try to detain the person making the threat, next call the police, and finally notify and warn the potential victim.
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Used by thousands of medical students each year to succeed on. More than in-depth cases covering every discipline. Designed to work with Kaplan's Step 2 High Yield course, this edition features exam-style questions.
Her father was diagnosed with colon cancer at age 43, and her mother was diagnosed with breast cancer at age She is sexually active with multiple partners and has not seen a physician since a car accident 15 years ago. She denies any symptoms at this time, and her physical examination is normal.
She asks what is recommended for a woman her age. Screening tests are done on seemingly healthy people to identify those at increased risk of disease. However, even if a diagnostic test is available, that does not always mean it should be used to screen for a particular disease. That is because diagnostic tests may:. The 4 malignancies for which regular screening is recommended are cancers of the colon, breast , cervix, and lung.
If there is no significant family history of colon cancer, screen everyone starting age Mammography plus manual breast exam are used to screen for breast cancer. Self-breast exam by itself is not recommended as a screening tool. In average risk women, screen as follows:. Current recommendations for lung cancer screening are as follows:. Answer: C. A bone density test uses x-rays to measure how many grams of calcium and other bone minerals are packed into a segment of bone. The bones typically tested are the spine, hip, and forearm.
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