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USMLE

®

STEP 1
Lecture Notes
2016

Behavioral Science
and Social Sciences

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D
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D
...
D
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P
...

Executive Director of Academics
Kaplan Medical
New York, NY

Basic Science of Patient Safety

Ted A
...
D
...
S
...
A
...
S
...
vii

Section I: Epidemiology and Biostatistics


Chapter 1: Epidemiology
...
19

Section II: Behavioral Science


Chapter 3: Life in the United States
...
55



Chapter 5: Human Sexuality
...
75



Chapter 7: Defense Mechanisms
...
99



Chapter 9: Human Development
...
123



Chapter 11: Physician-Patient Relationship
...
145



Chapter 13: Organic Disorders
...
183



Chapter 15: Ethical and Legal Issues
...
211

Section III: Social Sciences


Chapter 17: Basic Science of Patient Safety
...
245
v

Preface

These volumes of Lecture Notes represent the most-likely-to-be-tested material
on the current USMLE Step 1 exam
...
What do you like about the Notes? What could
be improved? Please share your feedback by e-mailing us at medfeedback@
kaplan
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Best of luck on your Step 1 exam!
Kaplan Medical

vii

SECTION

I

Epidemiology and
Biostatistics

Epidemiology

1

Learning Objectives
❏❏ Answer questions about epidemiologic measures
❏❏ Use knowledge of understanding screening tests
❏❏ Explain information related to study designs

EPIDEMIOLOGIC MEASURES
Epidemiology is the study of the distribution and determinants of health-related
states within a population
...

l The tools of epidemiology are numbers
...

l The denominator is key: who is “at risk” for a particular event or disease
state
...

Actual cases
Numerator
=

Potential cases
Denominator
l

= RATE

Rates are generally, but not always, per 100,000 persons by the Centers
for Disease Control and Prevention (CDC), but can be per any multiplier
...
)

Incidence and Prevalence
1
...

The numerator is the number of NEW events that occur in a defined
period; the denominator is the population at risk of experiencing this
new event during the same period
...

l Should not include cases that occurred or were diagnosed earlier
...

Examples:
a
...
We would then
say the incidence of prostate cancer in this population was 0
...

b
...
TwentyA
five medical students develop symptoms consistent with acute infectious diarrhea and are confirmed by laboratory testing to have been
infected with campylobacter
...

The denominator (person-time at risk) could be calculated by:

[(100 students at risk at the beginning of Sept
...
) / 2 ] × 2 months

= [(175 / 2) × 2] months

= 175 person-months of risk

Since 25 students got campylobacter in September or October, there
are 75 students remaining at risk at the end of October
...
It is the number of
exposed people infected with the disease divided by the total
number of exposed people
...
It is often referred to as an attack ratio
...
714 or about 71
...


Consider an outbreak of Norwalk virus in which 18 persons in 18 different households all became ill
...
8%
...
Prevalence rate: all persons who experience an event in a population
...


4

Chapter 1

Prevalence rate =

All cases of a disease at a given point/period
Total population “at risk” for being cases at a given point/period

l

Epidemiology

 10n

Prevalence is the proportion of people in a population who have a particular disease at a specified point in time, or over a specified period of time
...
A case is counted in prevalence until death or recovery
occurs
...

l Prevalence is most useful for measuring the burden of chronic diseases such as tuberculosis, malaria and HIV in a population
...
Since the number (20%)
includes ALL cases of obesity in the United States, we are talking about
prevalence
...
Prevalence is a measurement of
all individuals (new and old) affected by the disease at a particular time,
whereas incidence is a measurement of the number of new individuals
who contract a disease during a particular period of time
...
Period Prevalence The amount of disease present in a population changes over time
...

a
...
To do that, we need to calculate the point prevalence on a given date
...

The denominator would be the population of Community A that
day
...

b
...
Focus on chronic conditions
3
...
Prevalence = Incidence × Duration (P = I × D)
b
...
Incident cases or new cases are monitored over time
...

New cases join pre-existing cases to make up total prevalence
...

Prevalent cases leave the prevalence pot in one of two
ways: recovery or death
...
Prevalence Pot

4
...
Mortality rate: rate of death in a population at risk; refers to incident
cases only

Table 1-1
...
Calculating Incidence and Prevalence

Crude, Specific, and Standardized Rates
1
...
Specific rate: actual measured rate for subgroup of population, e
...
,
“age-specific” or “sex-specific” rate
...
Each component of that sum has the
following form:
(proportion of the population in the specified age group) × (age-specific rate)
3
...
g
...
The standardized rate adjusts or removes any difference between two populations
based on the standardized variable
...


7

USMLE Step 1

l

Behavioral Science and Social Sciences

Table 1-2
...

Why does Population A have a higher crude rate of disease compared with
Population C? (Hint: Look at the age distribution
...
Disease Rates Positively Correlated with Age
Population A

Population B

Population C

Cases

Cases

Population

Cases

Population

Younger

1

1,000

2

2,000

3

3,000

Intermediate

4

2,000

4

2,000

4

2,000

Older

9

3,000

6

2,000

3

1,000

Total

14

6,000

12

6,000

10

6,000

Crude Rates
per 1,000

8

Population

2
...
0

1
...
Screening Results in a 2 × 2 Table
Disease
Present
Screening Test Results

Positive

TP

Negative
Totals

60

Absent

Totals

FP 70

TP+FP

FN 40

TN

TN+FN

TP+FN

TN+FP

30

TP+TN+FP+FN

TP=true positives; TN=true negatives; FP=false positives; FN=false negatives

Pre-test Probabilities
Sensitivity and specificity are measures of the performance of different tests
(and in some cases physical findings and symptoms)
...
Think
about what would happen if you called the cardiology fellow to do a cardiac catheterization (the gold standard test to diagnose acute myocardial ischemia) on a
patient without having an EKG
...
That’s what sensitivity and specificity measures: the limitations and deficiencies of our every-day tests
...
ensitivity: the probability of correctly identifying a case of disS
ease
...
This is also known as the “true positive rate
...
Measures only the distribution of persons with disease
ii
...
Note: 1-sensitivity = false negative rate
If a test has a high sensitivity then a negative result would indicate the
absence of the disease
...

So, 100% of patients with TA have elevated ESR
...
If a patient you suspect of having TA has a
normal ESR, then the patient does not have TA
...
pecificity: the probability of correctly identifying disease-free perS
sons
...
This is also
known as the “true negative rate
...
Measures only the distribution of persons who are disease-free
ii
...
Note: 1-specificity = false positive rate
If a test has a high specificity then a positive result would indicate
the existence of the disease
...
A CT scan read as positive
for pulmonary embolism is likely true
...
This tradeoff can be represented graphically as the screening dimension curves
(figure 1-3) and ROC curves (figure 1-4)
...
 ositive predictive value: the probability of disease in a person who
P
receives a positive test result
...
(i
...
, has the disease) is referred to as
the “predictive value of a positive test
...

Measures only the distribution of persons who receive a positive test result
ii
...
 egative predictive value: the probability of no disease in a person
N
who receives a negative test result
...
e
...
”
Negative predictive value = TN/(TN + FN)

= true negatives/

(true negatives + false negatives)
i
...
Uses data from the bottom row of the 2 × 2 table
c
...

Accuracy = (TP + TN)/(TP + TN + FP + FN)

= (true positives + true negatives)/total screened patients

10

Chapter 1

l

Epidemiology

Practice Questions
1
...
)
2
...
)
A

B

C

Healthy

Low

D

E

Diseased

Blood Pressures

High

Figure 1-3
...
Which cutoff point provides optimal sensitivity? (B) Specificity? (D)
Accuracy? (C) Positive predictive value? (D)
2
...
0
0
...
8

D

0
...
6

B

0
...
4

A

0
...
2
0
...
1

0
...
3 0
...
5 0
...
7 0
...
9 1
...
Receiver Operating Characteristic (ROC) Curves

Practice Question
1
...
Reliability: ability of a test to measure something consistently, either
across testing situations (test-retest reliability), within a test (split-half
reliability), or across judges (inter-rater reliability)
...
(Precision)
2
...

Think of a marksman hitting the bull’s-eye
...
(Accuracy)

Types of bias
1
...
Examples:
a
...
Berkson bias: using only hospital records to estimate population
prevalence
c
...
Solution: random, independent sample; weight data
2
...
Examples:
a
...
g
...
Hawthorne effect: subjects’ behavior is altered because they are being studied
...
Solution: have a control group
3
...
Solution: double-blind design, where neither the subject
nor the investigators who have contact with them know which group receives the intervention under study and which group is the control
4
...
Example: Patients seem to live longer with the disease after it is uncovered by a
screening test
...
Solution: use life-expectancy to assess benefit

12

Chapter 1

l

Epidemiology

Diagnosis
Onset
Unscreened

0

Screened,
early treatment
not effective

0

Screened,
early treatment
is effective

0

Early

Usual

Death

DX
DX

Lead time

DX

Improved
survival

Figure 1-5
...
Recall bias: subjects fail to accurately recall events in the past
...
Solution: confirmation
6
...
Example: a recent survey
found that persons with AIDS reported only mild symptoms
...
Confounding bias: factor being examined is related to other factors
of less interest
...
More than one explanation can
be found for the presented results
...
Are differences in heart disease
due to exercise or to age? Solution: combine the results from multiple
studies, meta-analysis
8
...
Most common issue is non-comparable control group
...
Solution: random assignment
...


13

USMLE Step 1

l

Behavioral Science and Social Sciences

Table 1-5
...

S
 ystematic error is bad and biases
result (a threat to validity)
...
Case report: brief, objective report of a clinical characteristic or outcome from a single clinical subject or event, n = 1
...
g
...
No control group
2
...
E
...
, patients at local hospital with treatment-resistant TB
...
Cross-sectional study: the presence or absence of disease and other
variables are determined in each member of the study population or
in a representative sample at a particular time
...

a
...

b
...
Example: who in the community now has treatment-resistant TB
4
...
Almost always retrospective
...
g
...
Cannot assess incidence or prevalence of disease
b
...
Very useful for studying conditions with very low incidence or
prevalence
5
...
Outcome is disease incidence in
each group, e
...
, following a prison inmate population and marking the
development of treatment-resistant TB
...
Prospective; subjects tracked forward in time
b
...
Must follow population long enough for incidence to appear

Case-Control

CrossSectional

Cohort

Figure 1-6
...
For cross-sectional studies: use chi-square (x2)
2
...
Incidence rate of exposed group divided by the incidence rate of
the unexposed group
b
...
E
...
, if infant mortality rate in whites is 8
...
0 in blacks per 1,000 live births, then the relative risk of blacks
versus whites is 18
...
9 = 2
...
Compared with whites,
black infants are twice as likely to die in the first year of life
...
For statistical analysis, yields a p-value


l

Cohort Study
Disease

No Disease

Risk
Factor

60 A

240 B

No Risk
Factor

60 C

540 D

ttributable risk (AR): comparative probability asking “How many
A
more cases in one group?”
a
...
Using the same example, attributable risk is equal to 18
...
9 = 9
...
Of every 1,000 black infants, there were 9
...
In this case attributable
risk gives the excess mortality
...
Note that both relative risk and attributable risk tell us if there are
differences, but do not tell us why those differences exist
...
Number Need to Treat (NNT) = Inverse of attributable risk (if
looking at treatment)
How many people do you have to do something to stop one case
you otherwise would have had?
Note that the Number Needed to Harm (NNH) is computed the
same way
...

NNH = Inverse of attributable risk (if looking at exposure)
l 18/1,000 – 8/1,000 = 10/1,000 = AR
l Inverse of 10/1,000 = 100 = NNT or NNH
l 
Interpretations: for every 100 people treated, 1 case will be
prevented

15

USMLE Step 1

l

Behavioral Science and Social Sciences

3
...
Odds of exposure for cases divided by odds of exposure for
controls
b
...
Case-Control Study: Lung Cancer and Smoking
Lung Cancer

No Lung Cancer

Smokers

659 (A)

984 (B)

Nonsmokers

25

348 (D)

(C)


A/C AD
c
...
Use OR = AD/BC as working formula
e
...
32
BC 984 × 25
f
...

g
...

Practice Question
How would you analyze the data from this case-control study?

Table 1-7
...
0

Interpretation: this means that the odds of having a family history of colorectal
cancer are five times greater for those who have the disease than for those who
do not
...
Differentiating Observational Studies
Characteristic

Cross-Sectional Studies

Case-Control Studies

Cohort Studies

One time point

Retrospective

Prospective

Incidence

NO

NO

YES

Prevalence

YES

NO

NO

Causality

NO

YES

YES

Prevalence of disease

Begin with disease

End with disease

Association of risk factor and
disease

Many risk factors for
single disease

Single risk factor affecting
many diseases

Chi-square to assess
association

Odds ratio to estimate risk

Relative risk to estimate risk

Time

Role of disease
Assesses
Data analysis

Clinical trials (intervention studies): research that involves the
administration of a test regimen to evaluate its safety and efficacy
1
...

In clinical trials, this is most often a placebo group
...

2
...

a
...
Phase Two: testing protocol and dose levels in a small group of patient volunteers
c
...
Phase III is considered the definitive test
...
Post-marketing Survey: collecting reports of drug side-effects
when out in common usage (post-FDA approval)
3
...
Subjects in the study are randomly allocated into “intervention”
and “control” groups to receive or not receive an experimental
preventive or therapeutic procedure or intervention
...
Generally regarded as the most scientifically rigorous studies
available in epidemiology
c
...
Double-blind means that neither subjects nor researchers who have contact with them know
whether the subjects are in the treatment or comparison group
...
Community trial: experiment in which the unit of allocation to receive a

17

USMLE Step 1

l

Behavioral Science and Social Sciences

preventive or therapeutic regimen is an entire community or political
subdivision
...
Cross-over study: for ethical reasons, no group involved can remain
untreated
...

Also makes recruitment of subjects easier
...
Assume double-blind design
...
For second 3 months, Group B receives
AZT and Group A is control
...
Cross-Over Study

18

Chapter 2

The Genetic Code, Mutations
and Biostatistics
Translations

l

Biostatistics

2
4

Learning Objectives
❏❏ Demonstrate understanding of key probability rules
❏❏ Summarize data
❏❏ Solve problems using inferential statistics
❏❏ Use knowledge of nominal, ordinal, interval, and ratio scales
❏❏ Answer questions about statistical tests

KEY PROBABILITY RULES
Independence: across Multiple Events
a
...
Events are independent if the occurrence of one tells
you nothing about the occurrence of another
...


ii
...
g
...
3 and the
chance of having a cold is 0
...
3 × 0
...
06
(or 6%)
b
...
Multiply the probability of one event by the probability
of the second, assuming that the first has occurred
...
E
...
, if a box has 5 white balls and 5 black balls, the chance
of picking 2 black balls is: (5/10) × (4/9) = 0
...
44 =
0
...
Combine probabilities for mutually exclusive events by addition

i
...
The issue
here is the union of two sets
...
E
...
, if a coin lands on heads, it cannot be tails; the two
are mutually exclusive
...
5 + 0
...
0
(or 100%)

19

USMLE Step 1

l

Behavioral Science and Social Sciences

b
...
The combination of probabilities is accomplished by
adding the two together and subtracting out the multiplied probabilities
...
E
...
, if the chance of having diabetes is 10% and the
chance of being obese is 30%, the chance of meeting
someone who is obese or has diabetes or both is: 0
...
3 – (0
...
3) = 0
...
Venn Diagram Representations of Mutually Exclusive and
Nonmutually Exclusive Events

Practice Questions
1
...
1 × 0
...
1 = 0
...
 hicago has a population of 10,000,000
...
60% × 10,000,000 = 6,000,000)
3
...
8 for a white
A
man and 0
...
For a married couple who are both white and
age 65, the probability that the wife will be a living widow 5 years later is:
(A) 90%
(B) 72%
(C) 18%
(D) 10%
(E) 8%
Answer: C
...
Chance of the wife being alive: 90%
...
Therefore, 0
...
2 = 18%
...
If the chance of surviving for 1 year after being diagnosed with prostate cancer
is 80% and the chance of surviving for 2 years after diagnosis is 60%, what
is the chance of surviving for 2 years after diagnosis, given that the patient is
alive at the end of the first year?
(A) 20%
(B) 48%
(C) 60%
(D) 75%
(E) 80%
Answer: D
...
” Out of 100 patients, 80 are alive at the end of 1 year and 60 at the end of 2 years
...
Therefore, 60/80 = 75%
...
These distributions are summarized by a central tendency and variation around that center
...
This “bellshaped” curve is symmetric, with one side the mirror image of the other
...
Measures of Central Tendency

Central tendency
a
...

l  ean (X) (a synonym for average): the sum of the values of
M

the observations divided by the numbers of observations
l  edian (Md): the simplest division of a set of measurements is into
M
two parts — the upper half and lower half
...
The measurement
below which half the observations fall: the 50th percentile
l Mode: the most frequently occurring value in a set of observations

21

USMLE Step 1

l

Behavioral Science and Social Sciences

Given the distribution of numbers: 3, 6, 7, 7, 9, 10, 12, 15, 16
The mode is 7, the median is 9, the mean is 9
...
Sometimes the curve is
skewed either positively or negatively
...
A negative
skew has the tail to the left and the median greater than the mean
...


l

Negatively skewed

Positively skewed

X Md

Md X

Figure 2-3
...
But the range is unstable and changes easily
...

a
...
This will
give us both positive and negative values
...
The squared deviations are added together and divided by the number of cases
...


s=



22

(XX)2

n1



The square of the standard deviation (s2) equals the variance
...
Comparison of 2 Normal Curves with the Same Means,
but Different Standard Deviations

X1

X2

X3

Figure 2-5
...
You will not be asked to calculate a standard deviation or variance
on the exam, but you do need to know what they are and how
they relate to the normal curve
...


i
...
Within two standard deviations: 95
...
Within three standard deviations: 99
...
7%
95
...
15%

2
...
5%

:2s

:1s

34%

34%
X

13
...
4%

+2s

0
...
Percentage of Cases within 1, 2, and 3 Standard
Deviations of the Mean in a Normal Distribution

Know the constants presented in Figure 2-6 and be able to combine the given
constants to answer simple questions
...
 n a normal distribution curve, what percent of the cases are below 2s below
I
the mean? (2
...
 n a normal distribution curve, what percent of the cases are above 1s below
I
the mean? (84%)
3
...
5 percentile falls where on the curve? (2s above
A
the mean)
4
...
)

24

Chapter 2

l

Biostatistics

INFERENTIAL STATISTICS: GENERALIZATIONS FROM A
SAMPLE TO THE POPULATION AS A WHOLE
The purpose of inferential statistics is to designate how likely it is that a given
finding is simply the result of chance
...
However, because we
can rarely observe and study entire populations, we try to select samples that are
representative of the entire population so that we can generalize the results from
the sample to the population
...
Although the estimate given
from the sample is likely to be close, the true values for the population
may be above or below the sample values
...
Reality,
therefore, is most likely to be somewhere within the specified range
...
Assuming the graph (Figure 2-7) presents 95% confidence intervals,
which groups, if any, are statistically different from each other?

High

Blood
Pressure

Low
Drug A

Drug B

Drug C

Figure 2-7
...
Therefore, if the
graph represents 95% confidence intervals, Drugs B and C are no different in their effects; Drug B is no different from Drug A; Drug A has a
better effect than Drug C
...
0, then there is no statistically significant effect of exposure
...
77

(1
...
45)

Statistically significant (increased risk)

1
...
85 − 2
...
78

(0
...
94)

Statistically significant (decreased risk)



 RR > 1
...
0 and read as percent increase
...
77 means
If
one group has 77% more cases than the other
...
0, then subtract from 1
...
So 0
...

l

Understanding Statistical Inference
The goal of science is to define reality
...
We have all agreed to play the game according to the judgment calls of the
referee, even though we know the referee can and will be wrong sometimes
...
Define the research question: what are you trying to show?
b
...
Null hypothesis says that the findings are the result of
chance or random factors
...


ii
...
In this example, that the drug does actually work
...
Two types of null hypotheses

i
...
e
...
E
...
,
Group A is not < than Group B, or Group A is not >
Group B
ii
...
e
...
E
...
, Group A = Group B

Hypothesis testing
At this point, data are collected and analyzed by the appropriate statistical
test
...

a
...
The term p-value refers to two things
...

In the second sense, the p-value is a result of computation
...
The computed p-value is compared with the p-value
criterion to test statistical significance
...
In general, the smaller the p the better
...
The p-value criterion is traditionally set at p ≤ 0
...

(Assume that these are the criteria if no other value is
explicitly specified
...
05, reject the null hypothesis (reached statistical
l If
significance)
p > 0
...


l

Biostatistics



Note
We never accept the null hypothesis
...

Saying we do not have sufficient
evidence to reject it is not the same as
being able to affirm that it is true
...
13 (computed p value)

Possible
Outcome
#2

Do NOT Reject Null Hypothesis
Risk of type II, β error
p ≤ 0
...
02 (computed p value)

Possible
Outcome
#1

Reject Null Hypothesis
Risk of type I, α error
Figure 2-8
...
02, reject the null hypothesis, i
...
, decide that the
l If
drug works
p = 0
...
e
...
For some reason, the results given by the sample
may be inconsistent with the full population
...

There are two possible types of errors that we could make:
i
...
e
...
g
...
The chance of type I error is
given by the p-value
...
05, then the chance of a
type I error is 5 in 100, or 1 in 20
...
II error ( error): failing to reject the null
Type
hypothesis when it is really false, i
...
, declaring no
significant effect on the basis of the sample when there
really is one in the population, e
...
, asserting the drug
does not work when it really does
...


Note
l

 the null hypothesis is rejected,
If
there is no chance of a type II error
...


l 
Type

I error (error of commission)
is generally considered worse than
type II error (error of omission)
...
Provides criterion for making decisions about the null
hypothesis

ii
...
Tells statistical significance, not clinical significance or
likelihood of benefit

iv
...
In statistics, power is the capacity to detect a difference if
there is one
...
Just as increasing the power of a microscope makes it
easier to see what is going on in histology, increasing
statistical power allows us to detect what is happening in
the data
...
Power is directly related to type II error: 1 – β = Power
iv
...

The most common is to increase the sample size
...
Focus on nominal
To
and interval scales for the exam
...
Types of Scales in Statistics
Type of Scale

Description

Key Words

Examples

Nominal (Categorical)

Different groups

This or that or that

Gender, comparing among
treatment interventions

Ordinal

Groups in sequence

Comparative quality,
rank order

Olympic medals, class rank in
medical school

Interval

Exact differences
among groups

Quantity, mean, and
standard deviation

Height, weight, blood pressure,
drug dosage

Ratio

Interval + true zero point

Zero means zero

Temperature measured in
degrees Kelvin

28

Chapter 2

Nominal or Categorical Scale

l

Biostatistics

Note

A nominal scale puts people into boxes, without specifying the relationship between the boxes
...
Anytime you can say, “It’s either
this or that,” you are dealing with a nominal scale
...


The scales are hierarchically arranged
from least information provided
(nominal) to most information provided
(ratio)
...
g
...

For the USMLE, concentrate on
identifying nominal and interval scales
...
For
example, we say Ben is taller than Fred
...
We know something about the relationship between the categories (quality)
...
Class rank in medical school
and medals at the Olympics are examples of ordinal scales
...
In the scale of length, we know
that one inch is equal to any other inch
...
If a measurement has a mean and a standard deviation, treat it as an interval
scale
...
”

Ratio Scale
The best measure is the ratio scale
...
But it also has one additional quality: a true zero point
...
Measuring temperature using the Kelvin scale yields ratio
scale measurement
...
Types of Scales and Basic Statistical Tests
Variables
Name of Statistical Test

Interval

Nominal

Comment

Pearson Correlation

2

0

Is there a linear relationship?

Chi-square

0

2

Any # of groups

t-test

1

1

2 groups only

One-way ANOVA

1

1

2 or more groups

Matched pairs t-test

1

1

2 groups, linked data pairs, before and after

Repeated measures ANOVA

1

1

More than 2 groups, linked data

ANOVA = Analysis of Variance

29

USMLE Step 1

l

Behavioral Science and Social Sciences

Correlation Analysis (r, ranges from –1
...
0)

Note
Remember, your default choices are:
l

Correlation for interval data

l

a
...
g
...

b
...
g
...

c
...
A zero correlation means that two variables have no linear relation to one another, e
...
, height and success in medical school
...
Graphing correlations using scatterplots
i
...


ii
...


Chi-square for nominal data

l


t-test for a combination of nominal
and interval data

Note
You will not be asked to compute any of
these statistical tests
...


Strong, Positive
Correlation

Weak, Positive
Correlation

Strong, Negative
Correlation

Weak, Negative
Correlation

Zero
Correlation (r = 0)

Figure 2-9
...
NOTE: Correlation, by itself, does not mean causation
...
It does not mean that
one variable necessarily causes the other
...

a
...
Spearman correlation: compares 2 ordinal level variables

t-tests
a
...
Comparing the means of 2 groups from a single nominal variable, using means from an interval variable to see whether the
groups are different
c
...
e
...
E
...
, do patients
with MI who are in psychotherapy have a reduced length of convalescence compared with those who are not in therapy?
d
...
Matched pairs t-test: each person in one group is matched with
a person in the second
...
Comparison of the Distributions of Two Groups

Analysis of Variance (ANOVA)
a
...
One-way: compares means of many groups (two or more) of a
single nominal variable using an interval variable
...

c
...
Can test effects of several
variables at the same time
...
Repeated measures ANOVA: multiple measurements of same
people over time

Chi-square
a
...
Any number of groups (22, 23, 33, etc
...
Tests to see whether two nominal variables are independent, e
...
,
testing the efficacy of a new drug by comparing the number of
recovered patients given the drug with those who are not

Table 2-3
...
A recent study found a higher incidence of SIDS for children of mothers
who smoke
...
2
(E) 8
...
 researcher wishing to demonstrate the efficacy of a new treatment for
A
hypertension compares the effects of the new treatment versus a placebo
...
In this case, the null hypothesis should be
considered as
(A) positive proof that the stated premise is correct
(B) the assertion of a statistically significant relationship
(C) the assumption that the study design is adequate
(D) the probability that the relationship being studied is the result of random factors
(E) the result the experimenter hopes to achieve
3
...
The results yielded a mean of 14
...
55 and 14
...
This presented confidence limit is
(A) less precise, but has a higher confidence than 14
...
00
(B) more precise, but has a lower confidence than 14
...
00
(C) less precise, but has a lower confidence than 14
...
00
(D) more precise, but has a higher confidence than 14
...
00
(E) indeterminate, because the degree of confidence is not specified
4
...
The report included a correlation of +0
...
One of the possible interpretations of this correlation is:
(A) 
The statistic proves that there is no definable relationship between the
two specified variables
...

(C) A real-life relationship may exist, but the measurement error is too large
...

(E) The correlation is significant at the 0
...


32

Chapter 2

l

Biostatistics

Items 5 through 7
The Collaborative Depression study examined several factors impacting the detection and treatment of depression
...
For this research, a subpopulation of
300 persons was selected and subjected to the Dexamethasone Suppression Test
(DST)
...
Which of these ratios measures specificity?
6
...
Which of these ratios measures sensitivity?
8
...
However, subsequent,
more extensive research suggests that this initial conclusion was the result
of a Type I error
...
 survey of a popular seaside community (population =1,225) found the
A
local inhabitants to have unusually elevated blood pressures
...

Assuming a normal distribution for these assessed blood pressures, the
standard deviation for systolic blood pressure in this seaside community is
most likely
(A) 10
(B) 20
(C) 30
(D) 40
(E) 50

33

USMLE Step 1

l

Behavioral Science and Social Sciences

1
0
...
The report ended with the statement: chi-sq = 4
...
05
...
05
(C) if the drug were effective, the probability of the reported finding is less
than one in 20
(D) if the drug were ineffective, the probability of the reported finding is
less than 0
...
 recent study was conducted to assess the intelligence of students enrolled
A
in an alternative high school program
...
Based on this information it is most reasonable
to conclude that
(A) 50% of the students will have an IQ below the standard mean of 100
(B) 5% of the students will have IQs below 105
(C) students with IQs of 125 are at the 84th percentile
(D) 2
...
 correlation of +0
...
This correlation is significant at the 0
...

From this information we may conclude that:
(A) There is no association between alcohol consumption and systolic
pressure
...

(C) Men who consume less alcohol are at higher risk for increased systolic
pressure
...

(E) High systolic pressure can cause increased alcohol consumption in men
...
This same procedure was followed on a matched sample of persons living in Fort Collins, Colorado,
a smaller town located about 60 miles north
...


Table 1
...
This type of study can be best characterized as a
(A) cross-sectional study
(B) clinical case trial design
(C) cross-over study
(D) cohort study
(E) case-control study
1
4
...
67
(B) 5%
(C) 1
...
0
(E) 1
...

What statistical test would you run to test whether there was a difference
between the cumulative mortality rate for Denver and Fort Collins in 1985?
(A) t-test
(B) ANOVA
(C) Regression
(D) Correlation coefficient
(E) Chi-square

35

USMLE Step 1

l

Behavioral Science and Social Sciences

16
...

One hundred married males who had suffered infarcts were selected and
their average commuting time ascertained from either the subject, or if the
infarct had been fatal, their spouse
...
When examining this data for a possibly causal
relationship between commuting time and the occurrence of myocardial
infarcts, the most likely measure of association is
(A) odds ratio
(B) relative risk
(C) incidence rate
(D) attributable risk
(E) correlation coefficient
17
...
Only those people who have documented IQ scores at least two
standard deviations above the mean on the Wechsler Adult Intelligence
Scale, Revised (WAIS-R), are eligible for admission
...
 physician wishes to study whether moderate alcohol consumption is
A
associated with heart disease
...
60, the physician wants to have
a 95% chance of detecting an effect this large in the planned study
...
 ublic health officials were examining a suspicious outbreak of diarrhea
P
in an inner city community child-care center
...
Officials
discovered that children who drank liquids from a bottle were more likely
to have diarrhea than children who drank from a glass
...
The use
of bottles was subsequently banned from the center
...

Which of the following is the most likely source of bias in this study?
(A) Recall bias
(B) Lead-time bias
(C) Measurement bias
(D) Confounding
(E) Random differences as to the identification of diarrhea

36

Chapter 2

l

Biostatistics

0
...
This unusual occurrence led to the initiation of an investigation to try to determine the reason for this upsurge
...
The best type of study
to explore this possibility would likely be a
(A) cohort study
(B) case-control study
(C) cross-over study
(D) cross-sectional study
(E) community trial study
Items 21-30
Which statistical test will most likely be used to analyze the data suggested by the
following statements?
(A) t-test
(B) Chi-square test
(C) One-way ANOVA
(D) Two-way ANOVA
(E) Pearson correlation
(F) Matched pairs t-test
21
...

22
...

23
...
 researcher believes that boys with same-sex siblings are more likely to
A
have higher testosterone levels
...
 doctor believes that drawing blood is faster with a vacutainer for someA
one once that person is trained, but faster with a standard syringe for someone with no training
...

Twenty rats are coated with margarine and 20 with butter as part of a study
to explore the carcinogenic effects of oleo
...
 assess the efficacy of surgical interventions for breast cancer, the quality
To
of life, measured on a ten-point scale, of 30 women who underwent radical
mastectomies was compared with 30 women who received radiation treatments and 15 women who refused any medical intervention
...
Comparison of passing and failure rates at each of three test sites
...
Comparison of actual measured test scores for students at each of three test
sites
...

Assessing changes in blood pressure for a group of 30 hypertensives 1 week
before and 3 months after beginning a course of antihypertensive medication
...
 a study of chemical workers, 400 workers with respiratory disease and
In
150 workers without respiratory disease were selected for examination
...
Among workers with the respiratory disease, 250 gave a
history of exposure to the solvent, compared to 50 of the workers without
respiratory disease
...

The air quality is assessed in two Midwestern cities, one in which a government program has instituted reducing the amount of carbon monoxide
emissions allowed, and one without the government program
...
Given
the design of this study, an appropriate one-tailed null hypothesis would be
(A) air quality is related to respiratory problems in both of the cities under
study
...

(C) no evidence will be found for differences in air quality between the two
cities
...

(E) air quality will be inversely related to the rate of respiratory problems in
both cities
...

Answer: D
...
[230/71 = 3
...

Answer: D
...
Null hypothesis is a statement of chance,
the opposite of what the researcher hopes to find
...

Answer: B
...
Precise
means narrower interval
...

4
...
One reason for a near-zero correlation is that the error of measurement is so large that it obscures an underlying relationship
...
Does not mean cause
...

5
...
True negatives, out of all nondiseased
...
Note, divided by number ending in “0”
...

Answer: B
...
[TP/(TP+FP)] = [102/
(102+87)]
...

7
...
True positives, out of all diseased
...
Note, divided by number ending in “0”
...

Answer: A
...
This means that although statistical significance is
found, there is no real-world significance
...
Answer D is a good definition of a Type II error
...

Answer: B
...
This means that two standard deviations must equal 40 and that one standard deviation equals 20
...

Answer: D
...
” Ignore the chi-square value
...
05, this gives the chance of a Type I error
...

11
...
This is one standard deviation above the mean
...

Below this point are 84% of the cases using the normal curve
...

Answer: B
...
001 level
and can therefore be interpreted
...
Avoid answers that suggest a
causal relationship
...

Answer: D
...

14
...
Key is to focus only on 1981
...

[15%/10% = 1
...
5 times the risk
...

Answer: E
...
Dead versus alive is the second nominal variable
...


39

USMLE Step 1

l

Behavioral Science and Social Sciences

16
...
This is a case-control study (infarcts versus no infarcts)
...
The data is not incidence data, so relative risk
does not apply
...

Answer: E
...
What percent of the cases are above two standard deviations
above the mean? (2
...
5% of 400? (10)
18
...
Power is the chance of detecting a difference in the study if
there really is a difference in the real world
...

19
...
Bottle versus glass is confounded with age or maturity
...

20
...
Select suicide cases and compare with nonsuicides (controls)
...

Answer: F
...

Husbands and wives are nominal, but are nonindependent, matched pairs;
therefore, matched pairs t-test
...

Answer: B
...
Two nominal variables with a 2 × 3 design,
chi-square
...

Answer: E
...

Pearson correlation
...

Answer: A
...
Testosterone
level is assessed as ratio and treated as interval
...

25
...
Vacutainer versus standard syringe (nominal), training versus
no training (nominal), and time (interval)
...

26
...
Margarine versus butter (nominal), cancer versus no cancer
(nominal)
...

27
...
Three types of treatment: surgery, radiation, and none (nominal variable, three groups), quality of life on the given scale (interval)
...

28
...
Passing versus failure (nominal), three sites (nominal)
...

29
...
Three sites (nominal) with actual test scores (interval)
...

30
...
Before and after (nominal, two-groups, matched pairs), and
blood pressure (interval)
...

31
...
Respiratory (cases) versus nonrespiratory disease (controls), looking at history
...

Answer: D
...
“Not any lower than” satisfies this criterion
...
The divorce rate has been rising steadily for more than 40 years
...
It is estimated that nearly half of all marriages in the United States today
will end in divorce
...
As recent as 2012, the United States has had the sixth highest rate of
divorce worldwide
...
Women who are college graduates are less likely to divorce than women
who do not complete high school
...
Married individuals are associated with a higher Well-Being Index
Score than individuals associated with unmarried categories
...
The divorce rate among physicians is higher than for people of other
occupational groups
...
Marriage has a better chance of success if both partners are of similar
backgrounds, race, intelligence, and education
...
Divorce rates are higher for children of divorced parents, couples who
marry young, lower socioeconomic status (SES), very high SES
...
Divorced persons have the highest rates of hospitalization for mental
disorders
...
Divorce is hard on children: more behavior problems, delayed physical
and mental development
...

11
...


43

USMLE Step 1

l

Behavioral Science and Social Sciences
2011 Latest U
...
Separation, Divorce and Married Data
Marital Status

Well-Being Index Score

Married

68
...
0

Windowed

63
...
3

Divorced

59
...
9

National Adults

66
...
6%

11
...
6%

38
...
4%

22
...
5%

11
...
1%

6
...
SES: weighted combination of occupation and education
...

2
...
Exceptions to this are anxiety disorders and breast cancer in women, and more bipolar in either gender
...

3
...

4
...
More than 80% of single
families are headed by women
...
Annually, more than 35,000 commit suicide in the United States
and more than one million worldwide
...
Annually, as many as 600,000 (2
...

c
...
S
...
Between 10 and 20 suicide attempts for every one that succeeds

i
...
Women attempt suicide 3 times as often as men

44

Chapter 3

l

Life in the United States

e
...
Pills/poisons most likely method for
women to attempt suicide
f
...

g
...
S
...
2009 was 6
...
2011 rate was 7
...
These increasing numbers
reflect more teen suicides related to bullying
...
Lifetime prevalence of suicide ideation: 54%; past 12 months: 26%;
specific method: 10%
c
...

d
...
This age group has the highest rate for all ages of
Native Americans
...
Psychological autopsy studies show that almost all had some prior
mental illness, although most were undetected
...


i
...
Higher rates in single-parent families
iii
...
Educational prevention programs: increased knowledge but no
demonstrated change on rates
...
Best prevention: identify and address the underlying mental illness or substance abuse
...


Epidemiologic Facts
a
...
Rates 3 to 4 times rest of the population

ii
...
25% of suicides are older than 65

iv
...
The rate is also lower than younger Native Americans
...
More than 25% of all suicides are alcohol related
...
Roughly 80% have given some warning
...
80% have seen a physician in the past 6 months
...
50% have seen a physician in the past month
...
Rates are higher for:

i
...
Upper or middle classes versus lower classes

iii
...
Separated, divorced, widowed, or unemployed (Note:
singles are not at higher risk)

v
...
Persons discharged from mental hospitals: 34 times more likely to
commit suicide than the general population

i
...
Alcoholism: 15%

iii
...
Borderline personality disorder: 5%
f
...

g
...
Psychiatry is the highest subspecialty (although recent
data suggest that surgeons and family practice rates are
comparable)

ii
...
However, suicide rate for female physicians is four times
greater than general population
...

h
...
Suicide (especially violent suicide) is associated with lower serotonin levels
...
Risk Factors for Suicide
Previous suicide attempt(s) (#1 risk factor)
Family history of suicide
Male gender
Family history of child abuse
History of mental disorders, particularly clinical depression
History of alcohol and substance abuse
Feelings of hopelessness
Impulsive or aggressive tendencies
Cultural and religious beliefs (e
...
, belief that suicide is noble resolution of a
personal dilemma)
Local epidemics of suicide
Isolation, a feeling of being cut off from other people
Living alone
Barriers to accessing mental health treatment
Loss (relational, social, work, or financial)
Physical illness
Easy access to lethal methods
Unwillingness to seek help because of the stigma attached to mental health and
substance abuse disorders or to suicidal thoughts

46

Chapter 3

l

Life in the United States

25
Suicide
Homicide
Rate per 100,000 Population

20

15

10

5
†

0
0–9§

10–17

18–24

25–44

45–54

55–64

≥65

Age Group (yrs)
Adapted from CDC
...
5 deaths per 100,000 population
l Life expectancy: 78
...
15 deaths per 1,000 live births
l

Number of deaths for leading causes of death:


l
l
l
l
l
l
l
l
l
l

Heart disease: 597,689
Cancer: 574,743
Chronic lower respiratory diseases: 138,080
Stroke (cerebrovascular diseases): 129,476
Accidents (unintentional injuries): 120,859
Alzheimer’s disease: 83,494
Diabetes: 69,071
Nephritis, nephrotic syndrome, and nephrosis: 50,476
Influenza and Pneumonia: 50,097
Intentional self-harm (suicide): 38,364

Clinical Issues
a
...
Previous suicide attempt

ii
...
Having a plan

47

USMLE Step 1

l

Behavioral Science and Social Sciences

b
...

c
...

d
...
Recent years have seen a rise in chronic conditions, decline in the
number of patients with acute conditions
...
Since 1960, the death rate for heart disease has declined, while the
rate for cancer has increased
...
People age >65 visit the physician about twice as often as those age
<45
...

d
...
For men: essential hypertension

ii
...
The average length of hospital stay has been declining slowly but
steadily since 1970
...
9 days
...
Average hospital occupancy rate is about 69% nationwide
...
50% is the break-even point for a hospital
...
Largest portion of hospital budget is for personnel
g
...

h
...

i
...


Mental Illness
a
...

b
...

c
...
Development of medication
ii
...
Most psychiatric care hospitals are run by states
...
One in 10 persons will be hospitalized at some time in their lives
for psychiatric reasons (includes substance-related disorders)
...
Most admissions: psychiatric reasons
b
...
Most days lost from work: diseases of upper respiratory system
d
...
Most work-related disability: muscle/skeletal problems

Health Care Payments
a
...
Payments are made
for number of people the provider is responsible for, not care
delivered
...
Medicare: federal government program that provides insurance payment for the elderly, the disabled, and dependents of
the disabled
...
Medicare does not generally cover routine physical exams,
nursing home care, or prescription drugs
...
Medicare does cover ambulance transport, dialysis, and
speech and occupational therapy
...
About 1,000,000 adults and 200,000 children in the U
...
are HIV-positive
(male 1:100, female 1:800)
2
...

3
...

4
...

a
...

b
...
Most dangerous sexual practice: anal intercourse
6
...
If the patient has AIDS today, most likely homo/bisexual man
8
...
Fastest growing method of HIV transmission: heterosexual contact
(especially for blacks and Hispanics)
a
...
Risk of acquiring for men is greater if contact occurs during
menses
...
Uncircumcised men are more likely to be seropositive and contract HIV during sex
...
HIV transmission rates
a
...
Risk from single encounter with man who is a member of a high
risk group: 1 in 20 to 1 in 2
c
...
Seroconversion from blood transfusion: 2 of 3
e
...
About 20% of these remain HIV-positive after 1 year
...
Breast-feeding increases transmission rate to 50%
...
AZT reduces risk by half (to about 10%)
...


MORBIDITY AND MORTALITY
For this section, patterns—not specific numbers—are what matter
...


Table 3-2
...
Top 3 Non-genetic Causes
of Death in the U
...


% of Total Deaths
Tobacco

19%

Diet/Activity

14%

Alcohol

5%

Cancer rates
a
...
5
...
More than 30 per 100,000 in 2008
b
...
Basal cell or squamous cell cancers: 900,000 cases per
year

ii
...
Melanoma: 42,000 cases per year, more than 7,000 deaths

iv
...
Leading Sites of Cancer Incidence and Death
Types of Cancer

Incidence

Deaths

Prostate

1

2

Lung

2

1

Colorectal

3

3

Breast

1

2

Lung

2

1

Colorectal

3

3

Males

Females

51

USMLE Step 1

l

Behavioral Science and Social Sciences

Table 3-5
...
S
...
4

Stroke (cerebrovascular diseases)

46
...
4 (approx
...
2

Diabetes mellitus

23
...
7

Influenza and Pneumonia

17
...
3

U
...
Deaths and Mortality
l Number of deaths: 2,468,435
l Death rate: 799
...
7 years
l Infant Mortality rate: 6
...
Top 3 Leading Causes of Death by Age Group
Rank

1 to 4

4 to 9

10 to 14

15 to 24

25 to 34

35 to 44

45 to 54

55 to 65

over 65

#1

Congenital
anomalies

Unintended
injuries

Unintended
injuries

Unintended
injuries

Unintended
injuries

Unintended
injuries

Neoplasia

Neoplasia

Neoplasia

Heart
disease

#2

Short
gestation

Congenital
anomalies

Neoplasia

Neoplasia

Homicide

Suicide

Unintended
injuries

Heart disease

Heart
disease

Neoplasia

#3

52

Less than 1

SIDS

Neoplasia

Congenital
anomalies

Suicide

Suicide

Homicide

Heart disease

Unintended
injuries

Bronchitis,
asthma,
emphysema

Cerebrovascular

Chapter 3

l

Life in the United States

Table 3-7
...
Rates per 1,000 live births

i
...
0

ii
...
3
iii
...
6
other Hispanics: 6
...
Native Americans: 8
...
Overall: 7
...
Top 3 reasons for death:

i
...
Low birth weight (1,500 g) and respiratory distress: 18%
iii
...
Key facts

i
...

killer of African American infants is low birth
l 1
#
weight
is #2 for African Americans
l SIDS

ii
...


53

Substance-Related Disorders

4

Learning Objectives
❏❏ Use knowledge of physiology of substance-related disorders
❏❏ Use knowledge of alcohol and alcoholism
❏❏ Demonstrate understanding of common abused substances
❏❏ Explain information related to other abused substances
❏❏ Demonstrate understanding of substance-abusing physicians

PHYSIOLOGY OF SUBSTANCE-RELATED DISORDERS
The addiction pathway in the brain is a dopamine pathway
...

Mesolimbic pathway
Stimulus → Cerebral Cortex → Ventral Tegmental Area → Nucleus Accumbens
– food
– drugs
– sex
– kindness
Dopamine
(↑ desire
for stimulus)

Serotonin
(gives body the impression
of satisfaction so cravings
are reduced)

Drugs working in nucleus accumbens
Amphetamines
Cocaine
Opiates
TCH
PCP
Nicotine
Ketamine
Drugs working in ventral tegmental area
Opiates
Alcohol
Barbiturates
Benzodiazepines

55

USMLE Step 1

l

Behavioral Science and Social Sciences

ALCOHOL AND ALCOHOLISM
1
...
Nevertheless, tobacco accounts for more loss of life
...

b
...

2
...

a
...

b
...
Most widely used illicit drug for teenagers and marijuana most
widely used illicit drug
...
ince 1980, per capita consumption of alcohol has declined
...
The proportion of heavy drinkers
younger than 20 has increased
...
Alcoholism rates are higher for the low-SES groups, but they recover
sooner
...
Alcohol use has been implicated in 15% of all auto accidents
...
Alcohol use implicated in 50% of all
a
...
Auto accident deaths
c
...
Hospital admissions
7
...
The leading known cause of intellectual disability (Down syndrome
is second)
b
...
Consumption of large quantities of alcohol needed to produce FAS
8
...
Concordance rates: MZ > DZ (MZ = 60%, DZ = 30%)
b
...
Capacity to tolerate alcohol is the key (enzyme induction, lack of
tyrosine kinase)
d
...

e
...


56

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Substance-Related Disorders

9
...
Have you ever tried to Cut down on alcohol intake and not
succeeded?
b
...
Have you ever felt Guilty about your drinking behavior?
d
...
Medical complications of alcohol abuse

Cirrhosis, alcoholic hepatitis, pancreatitis, gastric or duodenal ulcer, esophageal varices, middle-age onset of diabetes, gastrointestinal cancer, hypertension, peripheral neuropathies, myopathies, cardiomyopathy, cerebral
vascular accidents, erectile dysfunction, vitamin deficiencies, pernicious
anemia, and brain disorders, including Wernicke-Korsakoff syndrome
(mortality rate of untreated Wernicke is 50%; treatment is with thiamine)
11
...

12
...
Most successful way to get person into treatment is to be referred by employer
b
...
S
...
The original 12-step program
...
Provides substitute dependency, social support, inspiration and hope, and external reminders that drinking is
aversive
...
Spiritual program
c
...
Stages of behaviorial change

i
...
Contemplation: aware of problem but ambivalent about
action

iii
...
Small steps taken
...
Action: change begins
...


v
...
Focus on relapse
prevention
...
Relapse: efforts to change abandoned
Cycle may repeat until sobriety is established
...
Pharmacologic treatments
a
...
Decreases alcohol consumption

ii
...
Should be used with psychotherapy (or 12-step program)

iv
...
Disulfiram Treatment

b
...
Reduces craving

58

Euphoria, hypervigilance, anxiety,
stereotyped behavior, grandiosity,
paranoia, tachycardia, pupillary
dilation

Amphetamines (release DA)

Restlessness, agitation, insomnia,
diuresis, GI disturbances, excitement

Impaired motor coordination,
anxiety, slowed reaction time,
impaired judgment, conjunctival
injection, dry mouth, increased
appetite, psychosis
Hallucinations, illusions,
anxiety, ideas of reference,
depersonalization, pupillary dilation,
tremors, uncoordination
Belligerence, impaired judgment,
nystagmus, uncoordination, lethargy,
unsteady gait, crusting around nose/
mouth
None in usual doses but more
depression (2×), impotency, traffic
accidents, and more days lost from
work
Pupillary constriction, constipation,
drowsiness, slurred speech,
respiratory depression, bradycardia,
coma, death
Assaultive, combative, impulsive,
agitated, nystagmus, ataxia,
hypersalivation, muscle rigidity,
decreased response to pain,
hyperacusis, paranoia, unpredictible
violence, psychosis
Impaired judgment, slurred speech,
uncoordination, unsteady gait,
stupor, coma, death–barb confusion,
falls, memory problems for benzos

Caffeine

Cannabis (e
...
, marijuana,
hashish)

Hallucinogens (e
...
, LSD,
mescaline, ketamine)

Inhalants (glue, paint thinner)

Nicotine

Opiates (heroin, codeine,
oxycodone)

Phencyclidine (PCP, angel dust)

Sedative hypnotics
(barbituates, benzodiazepines)

Cocaine (prevent re-uptake of
DA)

Intoxication

Substance

Table 4-2
...
Also called “E”, X or XTC
b
...
Effects begin in 45 minutes and last 2 to 4 hours
...

Symptoms include derealization, hallucinations, mania-like
mood, hyperthermia, hypertension, convulsions, and death
...
Fatigue the day after use

Anabolic Steroids
a
...
With chronic use, can cause cardiomyopathy, bone mineral loss with
later osteoporosis, hypertension, diabetes, atrophy of testis, mood lability, depression, atypical psychosis
c
...
Men: breast development, scrotal pain, premature baldness

ii
...
Helpful Hints of Substance-Related Disorders
Paranoia

Cocaine/amphetamine intoxication

Depression

Cocaine/amphetamine withdrawal

Arrhythmias

Cocaine intoxication

Violence

PCP

Vertical nystagmus

PCP

Pinpoint pupils

Opiate overdose (treatment = naloxone)

Flu-like

Opiate withdrawal (treatment = clonidine)

Flashbacks

LSD

Seizures

Benzodiazepine/alcohol withdrawal

Death

Barbiturate withdrawal

Epidemiology
a
...

b
...


i
...
5 times
...
Prevalence of substance-related disorders in newly admitted psychiatric inpatients or outpatients is roughly 50%
...
These “dual diagnosis” patients are very difficult to treat
and tend to continue use when on inpatient wards
...
Substance-related disorders adds to the suicide risk of any underlying psychiatric diagnosis
...
50% of emergency department visits are substance related
...
Physicians tend to underdiagnose substance-related problems of
all types, especially those in women, high-SES patients (and other
physicians)
...
Psychiatrists and anesthesiologists have highest rates
...
Physician impairment issues are dealt with by the State Licensing Boards
...
 f you suspect that a colleague has a substance-related problem do the
I
following and in this order:
a
...

b
...

c
...


61

USMLE Step 1

l

Behavioral Science and Social Sciences

Review Questions
33
...

In others, the association is closer to that of the general population
...
 39-year-old divorced Hispanic woman presents with lethargy and fatigue
...
She confesses that she finds herself
crying “for no reason
...
She is given a preliminary diagnosis of uni-polar depression
...
 Jones has been complaining of a depressed mood for several months
...

His wife informs you that he tried to kill himself last month when he
reported hearing voices that told him to kill himself
...
When
questioned, he reported having “given up
...
Which of the following
would pose the greatest risk for future completed suicide?
(A) Feelings of helplessness
(B) Marital status
(C) Affective disorders
(D) Past suicide attempt
(E) Schizophrenia

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Substance-Related Disorders

36
...
In addition, the record indicates that the patient
has a history of substance-related disorder, although no specifics are provided
...
 21-year-old male patient is brought to the emergency department by his
A
parents, who are concerned because he was stumbling around their house,
waving his arms in the air, and would not respond verbally to their questions
...
A slight tremor is evident in his hands and his pupils are
dilated
...
He also admits to having recently taken an
illegal substance
...

The police bring a 22-year-old white male to the emergency department
...
When questioned, the patient
is paranoid
...
The patient had previously been treated
for opiate overdose
...

Parents who are concerned because their 17-year-old son is “just not himself ” bring him to the emergency department
...
Based on this initial presentation, the
boy is most likely intoxicated with
(A) caffeine
(B) cannabis
(C) cocaine
(D) LSD
(E) alcohol
(F) inhalants
(G) phencyclidine
(H) nicotine
(I) opiates
(J) sedative hypnotics

Answers
33
...
All options presented have suicide rates higher than the general
population, but schizoid personality disorder has the lowest associated rate
...

34
...
Being over age 45, male, in poor health and emerging from
depression are all risk factors for suicide, but none of these are true for
this patient
...

35
...
Past suicide attempt is the strongest risk factor
...

36
...
Alcohol is the most abused drug for any age
...

37
...
The patient presents behavior and symptoms of someone high
on hallucinogens
...

38
...
The presenting profile is most suggestive of PCP intoxication, which produces its behavioral effects by antagonism of the glutamate
receptors and the activation of dopamine neurons
...
Answer: I
...


64

Human Sexuality

5

Learning Objectives
❏❏ Use knowledge of sexual behavior in the United States
❏❏ Demonstrate understanding of paraphilic disorders, sexual dysfunction,
masturbation, and homosexuality
❏❏ Explain how sexuality and aging are related

SEXUAL BEHAVIOR IN THE UNITED STATES
In the United States, 95% of people have their first sexual experience outside of
marriage
...
Nearly 70% of all unmarried females are nonvirgins by age 19
(80% of males)
...
Nearly 4 in 10 teenage girls whose first intercourse experience happened at age 13–14 report that the sex was
unwanted or involuntary
...
Average age of first sexual experience: 16
b
...


i
...

ii
...
”
c
...


i
...


ii
...


Teenage Pregnancy
The Centers for Disease Control and Prevention reports that 305,388 babies
were born to women age 15–19 in 2012
...
S
...
Teens seem to be less sexually active, and more of those who are
sexually active seem to be using birth control than in previous years
...
S
...

l Nearly 80 percent of teenagers who become pregnant are unmarried
...

l The main rise in the teen pregnancy rate is among girls younger than 15
l Close to 25 percent of teen mothers have a second child within two
years of the first birth
...
About 1 million U
...
teenagers become pregnant each year
...
10% of all teenage girls

ii
...

b
...


i
...


ii
...

c
...

d
...

e
...
For mother:

l Leading cause of school dropout
risk for obstetric complications
l High

ii
...


l Possible lower level of intellectual functioning

l  roblems of single-parent family (increased risk of
P
delinquency, suicide)

Sexually Transmitted Diseases
a
...

b
...

c
...


i
...


ii
...

d
...
Cases have doubled since 1970
...
Rate now more than 20/100,000
e
...
Number of cases has declined by half since 1975
...
Since 1975, increase in resistant strains

66

Chapter 5

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Human Sexuality

Table 5-1
...


Table 5-2
...
Plateau phase is a stage of sustained excitement
...
Only men have a refractory period
...
Pedophilia: sexual urges toward children
...
Exhibitionism: recurrent desire to expose genitals to stranger
3
...
Begins early in childhood
4
...
Masochism: sexual pleasure derived from being abused or dominated

67

USMLE Step 1

l

Behavioral Science and Social Sciences

6
...
g
...
Transvestite fetishism: fantasies or actual dressing by heterosexual
men in female clothes for sexual arousal
7
...
Zoophilia: animals preferred in sexual fantasies or practices
9
...
Urophilia: combining sex and urination
11
...
Hypoxyphilia: altered state of consciousness secondary to hypoxia while
experiencing orgasm
...
Gender Identity and Preferred Sexual Partner of a Biologic Male
Common Label

Gender
Identity

Preferred
Sexual Partner

Heterosexual

Male

Female

Transvestite fetishism

Male

Female

Female

Male

Male

Male

Gender dysphoria (transsexual)
Homosexual

Gender identity: sense of maleness or femaleness, established by the age of 3 years
...
Male hypoactive sexual desire disorder: deficiency or absence of
fantasies or desires
...


Sexual Arousal Disorders
a
...
Women unable to achieve adequate vaginal lubrication

ii
...
Antihistamine and anticholinergic medications cause
decrease in vaginal lubrication
b
...
Assessment: postage stamp test, snap gauge (to test
physiological versus psychological)
ii
...
Female orgasm disorder

i
...
5% of married women older than 35 have never achieved
orgasm

iii
...
Treatment: fantasy, vibrators
b
...
Male ejaculates before or immediately after entering vagina

ii
...
Treatment: stop and go technique, squeeze technique, SSRIs

Genitopelvic Pain/Penetration Disorders
a
...
Recurrent and persistent pain before, during, or after intercourse

i
...
Not diagnosed if due to medical problems
c
...
Treatment: relaxation, Hegar dilators

MASTURBATION
1
...
Reasons
a
...
In children: normal, feels good
3
...
Equally common in men and women
5
...
Can lead to premature ejaculation in males who use it primarily to
reduce tension

HOMOSEXUALITY
1
...
4 to 10% of all males, 1 to 3% of all females
3
...
Behavioral patterns of homosexuals are as varied as those of heterosexuals
...
Same level and variations in sexuality as for heterosexuals

69

USMLE Step 1

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Behavioral Science and Social Sciences

4
...
Over 50% of homosexuals have children
6
...
Ego-syntonic: agrees with sense of self, person is comfortable
b
...
If ego-dystonic: sexual orientation distress
...
Increasing evidence of biologic contribution
...
Preference well established by adolescence
a
...
Describe duration of feelings with “As long as I can remember”
9
...
Report experiences as “ungratifying”
b
...
Sexual interest does not decline significantly with aging
...
Continued sexual activity means sexual activity can continue
...
Best predictor of sexual activity in the elderly is availability of a partner
...
After myocardial infarction (MI), sexual position that puts least strain
on the heart: partner on top
5
...
Slower erection
b
...
More stimulation needed
6
...
Vaginal dryness
b
...
Can be reduced by estrogen replacement

70

Chapter 5

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Human Sexuality

Review Questions
40
...

A
They say they have read that marital satisfaction changes over the course of
the marriage and want to know what they should expect over the course of
their own marriage
...

Your schedule indicates that you have an initial appointment with a patient
who is a 50-year-old white male
...

According to surveys by the Centers for Disease Control and Prevention, as
of 2000, the most common health problem in the United States is
(A) cancer
(B) heart disease
(C) substance-related disorder
(D) obesity
(E) dental caries
43
...
The physical exam shows the patient to be in good health, although
she is slightly overweight and has moderately elevated blood pressure
...

During a 1-year period, a physician practicing medicine in the United
States would be most likely to encounter a patient suffering from which of
the following mandatory reportable diseases?
(A) Hepatitis A
(B) Lyme disease
(C) HIV/AIDS
(D) Chicken pox
(E) Syphilis
45
...
Electricity
An
was shut off for several days, and many of the people in the area were homeless
...

You have been appointed to provide an assessment of the general health
status of your local community
...

Based on this information, your assessment should focus on
(A) hospital bed:population ratio
(B) infant mortality rate
(C) physician:patient ratio
(D) general mortality rate
(E) quality of the physical and social environment
47
...
“We have been fighting so much lately,” she says
...
” Medical
history shows that she has been taking diazepam for the past 2 years and
oral contraceptives for the past 5 years
...
 the conclusion of her annual gynecologic exam, a 34-year-old married
At
Hispanic woman confides to her physician that her interest in sex has been
“spotty” lately
...
She refrains from sexual intercourse during
menses
...
The physician’s
best response would be
(A) “What medications are you taking?”
(B) “Is your husband sometimes abusive?”
(C) “This is a normal pattern of sexual arousal reported by many women
...
”
(E) “How often does your husband want to have sex?”
(F) “I’m going to have you talk to a friend of mine who specializes in this
sort of thing
...
”
49
...
Suspecting the presence of a paraphilia, the physician should explore for further evidence of
(A) coprophilia
(B) transvestitism
(C) sadism
(D) frotteurism
(E) voyeurism
(F) exhibitionism
(G) pedophilia
(H) fetishism
(I) masochism
(J) zoophilia
(K) necrophilia
50
...
At this
point, the physician should inform the patient that
(A) loss of interest in sex is a natural part of aging
(B) although men maintain interest in sexual activity, women lose interest
as they age
(C) more mental and physical stimulation may be required to achieve erection
(D) sexual activity should be limited to once a month to reduce cardiovascular stress
(E)  will be provided with a prescription for an anti-impotence drug so
he
that it is available when he needs it

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USMLE Step 1

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Behavioral Science and Social Sciences

Answers
40
...
Marital satisfaction tends to be lower for couples with children,
and to rise when the children leave home
...

Answer: C
...

42
...
The key here is the phrase “health problem
...

43
...
For males in the same age range, the leading cause of death is
accidents
...

Answer: D
...

45
...
The aftermath of natural disasters finds many people suffering from distress reactions
...
After natural disasters, there tends to
be an increase in social organization
...

St
...
Adults adapt more quickly than children
...

46
...
The quality of the overall environment is the main issue
...
Infant mortality is one of the
strongest predictors of life expectancy, but not of overall health of the community
...

Answer: E
...

48
...
Many women report peak sexual arousal just prior to the onset
of menses
...
She needs
reassurance, not problem solving or medical intervention
...

Answer: I
...

50
...
Sexual interest does not decline with age for either men or
women
...


74

Learning and Behavior Modification

6

Learning Objectives
❏❏ Describe the major learning theories and explain how they predict
behavior change
❏❏ Explain information related to behavior therapy and behavior modification

LEARNING AND BEHAVIOR
In the behaviorist model of learning and behavior modification, internal states,
subjective impressions, and unconscious processes are not relevant
...
e
...
The
behaviorist definition of learning: a relatively permanent change in behavior, not
due to fatigue, drugs, or maturation
...


Classical Conditioning
UCS
Unconditioned Stimulus
(sight of food)
CS
Conditioned Stimulus
(bell)

UCR
Unconditioned response
(salivation)
CR
Conditioned response
(salivation)

Figure 6-1
...
In classical conditioning, the conditioned response is elicited by the conditioned stimulus after repeated pairings of the UCS and CS
...
The Pavlovian experiment paired the ringing of a bell with the
bringing of food so that, eventually, the sound of the bell elicited
the salivatory response, which previously occurred only with the
sight of the food
...
Or, for example, a patient receives chemotherapy (UCS), which induces nausea (UCR)
...

2
...
Note that the triggering
stimulus (CS) occurs before the response
...
Stimulus generalization: the tendency for the conditioned stimulus to evoke
similar responses after the response has been conditioned
...
Or, in the second example, generalization will have
occurred if any hospital, or even meeting a physician, comes to elicit nausea
from the patient
...
Extinction: after learning has occurred, removal of the pairing between
the UCS and the CS results in a decreased probability that the conditioned response will be made
...
The nausea-eliciting properties of hospitals will be extinguished
...
In operant conditioning, a new response is emitted, perhaps randomly
at first, which results in a consequence
...
The consequence acts as reinforcement and changes the probability of the response’s future occurrence
...
In the Skinner experiment, pressing a lever resulting in the delivery
of food
...

Because it changed behavior, the food is a reinforcing event
...
A new response occurs to an old stimulus
...

R1 (Usual Behavior)
S
R2 (Bar pressing)

Reinforcement
Figure 6-2
...
Reinforcement is delivery of a consequence that increases the likelihood
that a response will occur
...
Any
stimulus is a reinforcer if it increases the probability of a response
...
Types of reinforcers
a
...


i
...
g
...
E
...
, increased complaining leads to increased attention
from the nursing staff
b
...


i
...
g
...


76

Chapter 6

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Learning and Behavior Modification



ii
...
Positive and negative do not imply good and bad, respectively
...
Both positive and negative reinforcement lead
to an increase in response frequency or strength
...
Punishment, like negative conditioning, usually uses a noxious
stimulus
...
However, this stimulus is imposed to weaken response
...
Ordinarily, punishment should be paired with positive
reinforcement for alternative behaviors
...
E
...
, physical punishment of a child will suppress naughty
behavior, but may fade when the punishment is removed
and may model aggressive physical behavior for the child
...
Extinction refers to the disappearance of a response when it is no
longer being reinforced
...
E
...
, a nurse who is bombarded by constant complaints
from a patient stops paying attention to the patient
whenever he complains
...
E
...
, a child is ignored by the parents when he throws
temper tantrums
...
If successful, the unwanted behavior will stop
...
Types of Reinforcement
Stimulus: (S)
Add
Stops

Punishment

Extinction

Increases

Behavior: (R)

Remove

Positive reinforcement

Negative reinforcement


Note: A behavior is something that is done
...

5
...
Continuous reinforcement: every response is followed by a reinforcement
...
Results in fast learning (acquisition)

ii
...
Intermittent (or partial) reinforcement: not every response is reinforced

i
...
Response is harder to extinguish

iii
...
g
...

They don’t want to reinforce such behavior with attention
...


iv
...


77

USMLE Step 1

l

Behavioral Science and Social Sciences

v
...
Responses
are slow in the beginning of the interval and faster
immediately prior to reinforcement
...
g
...
g
...
schedules: based on the number of behaviors elicRatio
ited before reinforcement is given

l ixed ratio schedule delivers reinforcement after a
F
fixed number of responses
...
g
...


l  ariable ratio schedule delivers reinforcement after a
V
changing number of responses
...
Since any response may
be the lucky one, person keeps on trying
...
Reinforcement Schedules
Contingency
Time
Schedule:

Behaviors

Constant

Fixed interval (FI)

Fixed ratio (FR)

Changing

Variable interval (VI)

Variable ratio (VR)

6
...

7
...
g
...


78

Chapter 6

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Learning and Behavior Modification

Modeling, Observational, or Social Learning
1
...
Follows the same principles as in operant conditioning
3
...

4
...
Other applications: assertiveness training, social skills training, preparing
children for various frightening or painful medical or surgical procedures

BEHAVIOR THERAPY AND BEHAVIOR MODIFICATION
Focus on treating symptoms directly rather than changing underlying internal
conflicts
...
Systematic desensitization—usually begins with imagining oneself in a
progression of fearful situations and using relaxation strategies that compete with anxiety
...
Often used to treat anxiety and phobias
b
...
 1: Hierarchy of fear-eliciting stimuli is created, buildStep
ing from least to most stressful
...
2: Therapist teaches the technique of muscle relaxStep
ation, a response that is incompatible with anxiety
...
tep 3: Patient is taught to relax in the presence, real or
S
imagined, of each stimulus on the hierarchy from least to
most stressful
...
When the person is relaxed in the presence of the feared stimulus,
objectively, there is no more phobia
...
Note that this works by replacing anxiety with relaxation, an incompatible response
...
Exposure
a
...

b
...
E
...
, fear of heights treated by having patient to ride up elevator
d
...
Aversive conditioning occurs when a stimulus that produces deviant behavior is paired with an aversive stimulus
...
Key properties of the original stimulus are changed

i
...
g
...
The dog does not salivate, but instead recoils
as the spoiled meat is presented
...
Used in the treatment of alcoholism and some forms of sexual deviance

i
...
g
...
Shaping (or successive approximations)
a
...
Reinforcement is gradually modified to move behaviors from the
more general to the specific responses desired
...
E
...
, an autistic boy who won’t speak is first reinforced, perhaps
with candy, for any utterance
...
Eventually, reinforcement is contingent
on his using speech correctly in the proper context
...
Extinction
a
...
E
...
, if complaining results in a patient receiving a lot of attention,
stopping the attention will eventually stop the undesired behavior
...
E
...
, instituting a “time out” with children who are acting inappropriately or test-takers who are anxious
3
...
Sometimes stimuli inadvertently acquire control over behavior
...
E
...
, a person’s eating behavior is tied to a particular stimulus,
such as television watching
...

c
...
g
...

4
...
Using external feedback to modify internal physiologic states
b
...
We now know that both
animals and humans can attain a measure of control over some of
their own bodily functions through the technique of biofeedback
...
 ften uses electronic devices to present physiologic
O
information, e
...
, heart monitor to show heart rate
c
...

d
...

e
...
Galvanic skin response: reduced skin conductivity = anxiety reduction
g
...


80

Chapter 6

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Learning and Behavior Modification

5
...
Gradually removing the reinforcement without the subject discerning the difference
b
...
g
...
E
...
, gradually replacing postoperative painkiller with a placebo

Table 6-3
...

Step 2: Technique of muscle relaxation taught
...

Works by replacing anxiety with relaxation, an incompatible response

Exposure (also: flooding
or implosion)

Simple phobias treated by forced exposure to the feared object
...

Can help reduce deviant behaviors
...

Reinforcement gradually modified to move behaviors from general responses to the specific
responses desired
...
“Time out” with
children or for test-anxiety
...
When this is true, removal
of that stimulus can extinguish the response
...


Biofeedback

Using external feedback to modify internal physiologic states
...
g
...


Fading

Gradually removing the reinforcement: 1
...

while maintaining the desired response
Example: Gradually replacing postoperative painkiller with a placebo

Behavioral Models of Depression
1
...
Laboratory model of depression
b
...


i
...
Eventually,
the rat will not take an obvious avoidance route even
when it is offered
...
Symptoms of helplessness (in animals) include passivity, norepinepherine depletion, and difficulty learning responses that produce
relief, weight, and appetite loss

81

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Behavioral Science and Social Sciences

d
...
Increased levels of GABA in hippocampus decrease likelihood of
learned helplessness response
2
...
Another explanation for depression
b
...
Person may lack the social skills necessary to elicit this positive
reinforcement
...
Depression can be seen as a prolonged extinction schedule
...
Results in passivity

Special Topics
1
...
Reinforcement depends
on the internal state of the organism
...
Consider how likely you are to say “thank you” to a turkey sandwich offered when you missed lunch versus just after Thanksgiving dinner
2
...
Too much or too little anxiety has a disruptive effect on learning
...
This curvilinear relationship applies to:

i
...
Fear induction and adherence (health belief model)

iii
...
Stimulus complexity and personal preferences

v
...
Relationship between Anxiety
and Postoperative Adjustment
3
...
Involves no assumptions about physical or psychological origin of
pain (or even if person really is in pain)
b
...


82

Chapter 6

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Learning and Behavior Modification

c
...
Involves assessing changes in pain behavior and changing environmental contingencies, including medications
e
...
Contrasts with hospice

i
...
Emphasizes self-control and self-administered pain
medication

83

USMLE Step 1

l

Behavioral Science and Social Sciences

Review Questions
51
...
The concept of “learned
helplessness,” important for the understanding of the behavioral patterns
common in depressed patients, originates from animal studies in which the
experimenter prevents
(A) spontaneous recovery
(B) extinction behavior
(C) stimulus generalization
(D) operant reinforcement
(E) avoidance behavior
52
...
To most increase the
chances that the child will continue this behavior in the future, even when
the parents are not present, from this point forward reinforcement of the
child should follow what type of reinforcement schedule?
(A) Fixed ratio reinforcement
(B) Fixed interval reinforcement
(C) Variable ratio reinforcement
(D) Variable interval reinforcement
(E) Noncontingent reinforcement
53
...
Operant conditioning is most likely to account
for which of the following instances of crying in an 18-month-old child?
Crying that
(A) occurs spontaneously without any apparent cause
(B) increases in intensity when the adult does not respond
(C) occurs when the child is hungry
(D) occurs in response to an unexpected, sudden, painful stimulus
(E) occurs when the mother leaves the child in the care of a new babysitter
54
...
Exasperated, the mother says to one of
her sons, “Go to your room until you apologize to your brother for hitting
him!” The mother’s words are an example of the application of
(A) operant conditioning
(B) punishment
(C) aversive conditioning
(D) negative reinforcement
(E) extinction

84

Chapter 6

l

Learning and Behavior Modification

55
...
The child’s behavior can best be explained as an example of
(A) shaping
(B) instrumental conditioning
(C) mediated reflex response arc
(D) classic conditioning
(E) observational learning
56
...
When questioned by his
physician, he notes that he has the most trouble refraining from smoking
when he has his usual glass of bourbon every evening
...
The physician suggests
that he refrain from having his bourbon each evening and substitute an evening stroll instead
...
 56-year-old male patient has just been diagnosed with diabetes
...
The patient is most
likely to follow the instructions given by the physician if the conversation
with the physician makes the patient
(A) calm and collected
(B) calm and questioning
(C) concerned and attentive
(D) worried and distracted
(E) fearful and self-absorbed

Answers
51
...
In the animal studies, the researcher prevents the animal from
getting away from the painful stimulus: avoidance is prevented
...
Answer: C
...

Think of gambling
...
Answer: B
...
Pain response is not learned, but innate
...
Answer: D
...
This removal, making a
behavior more likely, is the definition of negative reinforcement
...
That would be “you have been fighting with your brother, go to your room,” trying to inflict punishment to
limit a behavior
...
Answer: D
...
Classic, or its synonym,
respondent conditioning
...
Answer: E
...
Note that this is an application
of operant conditioning
...
Answer: C
...


86

Defense Mechanisms

7

Learning Objectives
❏❏ Use knowledge of four clusters of defenses
❏❏ Demonstrate understanding of transference

GENERAL ISSUES
1
...

D
Recall that the Freudian psyche consists of:
a
...
Ego: rational and language-based executors linking to reality
c
...

2
...
They are
the means by which the ego wards off anxiety and controls instinctive
urges and unpleasant affects (emotions)
...
All defenses are unconscious, with one exception: suppression
b
...
We are only aware of our defenses in
retrospect
...
Defenses are adaptive as well as pathologic
...
They are how we cope
...
Psychopathology is an issue of intensity and extent
...

The key issue in psychopathology is the degree to which the use of
defense mechanisms is disruptive of a person’s ability to deal with
the world around him or her
...


FOUR CLUSTERS OF DEFENSES
(from least mature to most mature)

Narcissistic Defenses
The boundary between self and others is highly permeable
...


87

USMLE Step 1

l

Behavioral Science and Social Sciences

a
...
Internal states are perceived as a part of someone else or of the world in general
...
Examples:

l  man who has committed adultery becomes conA
vinced that his wife is having an affair even though
there is no evidence of it
...


l  physician believes that the nursing staff is uncomA
fortable talking to him, when in fact, he is uncomfortable talking with them
...
Paranoia results from the use of projection
...
Denial: not allowing reality to penetrate
...
Used to avoid becoming
aware of a painful aspect of reality

i
...

child who is abused insists that she has been treated well
...


ii
...
Substance users are often “in
denial,” claiming that they are not addicted and do not have
a problem in the face of clearly dysfunctional or dangerous
behavior
...
Splitting: people and things in the world are perceived as all bad or
all good (God or the Devil)
...


i
...
”
just so perfect and wonderful,” says a teenage girl in love
...
”

ii
...

Prejudice and stereotypes are often the result of splitting
...

a
...
Examples:
Jones, you are suffering from
...

“
remember what it is called
...

the middle of a conversation, a woman pauses, looks
l  n
I
confused, and asks, “What was I just talking about?”

ii
...

b
...
“Acting
childish” or at least younger than is typical for that individual

i
...

husband speaks to his wife in “baby talk
...

l 
A

ii
...
e
...

iii
...


iv
...
Similarly, when a new child is born, older
children who have been weaned may demand to go back
to breast-feeding
...
Somatization: psychic derivatives are converted into bodily symptoms
...


i
...
Extreme forms of somatization are diagnosed as somatic
symptom disorders (see section on DSM 5)
...
Symptoms created are physically real, not merely imagined
d
...
The opposite of projection

i
...

l A
child scolds herself out loud in the same manner that
l A
her mother scolded her the day before
...

l 
A

ii
...


iii
...

iv
...
“I
always swore that I would treat my children differently,
yet there I was saying the same things to my children that
my mother always used to say to me!”

89

USMLE Step 1

l

Behavioral Science and Social Sciences




v
...

vi
...


Anxiety Defenses
You have a fairly strong and robust sense of self and ego
...

a
...
Examples:
man who is angry at his boss pounds on his desk
l 
A
rather than telling his boss what he really thinks
...

married man who is sexually aroused by a woman he
l 
A
meets goes home and makes love to his wife
...
In family therapy, one child in the family is often singled
out and blamed for all the family’s problems, i
...
, is
treated as a scapegoat by others displacing their symptoms onto this child
...
Displacement often “runs downhill,” i
...
, from higher to
lower in a power hierarchy
...
Phobias are the result of displacement
...
Repression: an idea or feeling is eliminated from consciousness
...


i
...

man who survived 6 months in a concentration camp
l 
A
cannot recall anything about his life during that time period
...
You forget, and then forget that you forgot
...
Content usually not recoverable without some trauma or
psychoanalysis
iv
...
One of the most basic defense mechanisms
c
...
Separation of an idea from the affect that accompanies it

i
...

physician informs a patient of his poor prognosis in
l 
A
bland, matter-of-fact tones
...


ii
...
The bland affect of schizophrenics, la belle indifference,
that often accompanies conversion disorder is a manifestation of this defense mechanism
...
Intellectualization: affect is stripped away and replaced by an excessive use of intellectual processes
...
The
intellectual content is academically, but not humanly, relevant
...
Examples:

l  Notice how the bone is protruding from my leg
...
”
physician tells a patient about his poor prognosis
l 
A
and talks a great deal about the technical aspects by
which the prognosis was derived
...


l Intellect in place of emotion

ii
...

iii
...

e
...
Strong action or emotions to cover up
unacceptable emotions
...


i
...

adolescents, substance-related disorder, overeatl  or
F
ing, or getting into fights are “strong” actions that
coverup underlying feelings of vulnerability
...
Differentiated from displacement in that the emotion is
covered up, not redirected

iii
...
Rationalization: rational explanations are used to justify attitudes,
beliefs, or behaviors that are unacceptable
...
Examples:
I believe killing is wrong, but I killed him because
l  Yes,
“
he really deserved it
...


91

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Behavioral Science and Social Sciences


l  young single woman tells herself that engaging in
A
oral sex with a married man is not the same thing as
having a “sexual relationship” with him
...
Look for the “string of reasons”
iii
...


iv
...
Often accompanies obsessive–compulsive behavior
g
...
A global reversal in which love is expressed as hate,
for example

i
...


l  teenage boy intrigued by “dirty pictures” organizes an
A
antiporno-graphy campaign
...


ii
...
As if the person is trying to convince self,
or anyone else, that the original feeling or impulse did
not exist
...
”

iii
...
Undoing: acting out the reverse of unacceptable behavior
...
Examples:
man who is sexually aroused by woman he meets
l 
A
immediately leaves and buys his wife flowers
...


ii
...

iii
...
g
...

i
...
Regarded as a passive
(indirect) expression of hostility

i
...
”
student agrees to share class notes but goes home
l 
A
without sharing them
...


92

Chapter 7

l

Defense Mechanisms



ii
...


iii
...

iv
...
Dissociation: separates self from one’s experience
...
The facts of the events are accepted,
but the self is protected from the full impact of the experience
...
Examples:

l  woman who was raped reports that it was as if she
A
was floating on the ceiling watching it happen
...


l  child who was sexually abused recalls only the bad
A
man who came to her in her dreams
...
Increasingly common in clinical settings
iii
...
g
...


Mature Defenses
These defenses distort reality less than the other defenses and are thus
considered more mature
a
...
Examples:
laughs when told he is going to be fired
...


l  terminally ill cancer patient makes fun of his condition
...
Laughter covers the pain and anxiety
...
We laugh the easiest at the things that make us most anxious
...
Sublimation: impulse-gratification is achieved by channeling the
unacceptable or unattainable impulse into a socially acceptable
direction
...


i
...

executive who is attracted to a female associate
l  n
A
becomes her mentor and advisor
...

l A

ii
...

iii
...
Suppression: conscious decision to postpone attention to an impulse or conflict
...

The suppressed content temporarily resides in the unconscious
...
Examples:
student decides to forget about a pending exam to go
l A
out and have a good time for an evening
...

terminally ill cancer patient puts aside his anxiety
l 
A
and enjoys a family gathering
...
Unlike repression, suppressed content is recalled with the
right cue or stimulus
...
Forget, but remember that you forgot

TRANSFERENCE
The patient unconsciously transfers thoughts and feelings about a parent or significant other person onto his physician
...
Can
be positive (cause you to unaccountably like someone) or negative (cause you to
unaccountably dislike someone)
1
...
Not necessarily related to the length of time the patient has known
physician
3
...

4
...


94

Chapter 7

l

Defense Mechanisms

Table 7-1
...

“No, I don’t remember, and I don’t want to remember,” cries a man asked to
recall a painful episode from his childhood
...
 woman finds herself in a town some distance from her home, without
A
any recollection of how she got there
...

When asked about his impending heart operation, the patient recounts the
procedures in detail
...
He discusses the details for hours, yet shows no emotional reaction
to the impending events
...
 woman with no previous history of promiscuity suddenly begins to take
A
on sexual partners of both sexes, one right after the other
...
Yet, there is no indication of a period of
mourning
...
 32-year-old Irish male appears at the clinic complaining of “a slight pain”
A
on his left side
...

When informed of this, the man insists that it cannot be that serious and
asks only for some medication for the pain
...
 father, who has lost his daughter as the result of a traffic accident involvA
ing a drunk driver, organizes a local chapter of a national group campaigning to stop the sale of liquor to minors and to legislate mandatory jail time
for anyone convicted of drunk driving
...
The
defense mechanism that most likely accounts for this behavior is
(A) acting out
(B) suppression
(C) reaction formation
(D) displacement
(E) sublimation
64
...
His life was saved by the administration of
emergency balloon angioplasty
...
Much to his surprise, he finds the
patient, who never did much exercise before, on the floor doing push-ups
and saying, “Time to get in shape, doc!” The patient’s word and behavior
in this instance are most likely the result of the defense mechanism of
(A) denial
(B) dissociation
(C) acting out
(D) undoing
(E) reaction formation

97

USMLE Step 1

l

Behavioral Science and Social Sciences

65
...

One day after he had had an argument with his wife, Bob got into a fistfight
during a football game and had to be restrained by his teammates
...
Answer: E
...
It is
enduring and motivated by unconscious desires
...

59
...
Amnesia with travel is the classic definition of psychogenic
fugue state, the result of dissociation as a defense mechanism
...
Answer: E
...

Anxiety is replaced by cognitive activity: intellectualization
...
Answer: D
...
This behavior masks the underlying,
unexpressed feeling and constitutes acting out
...
Answer: B
...
This bald-faced negation of objective facts is denial
...
Answer: E
...
The behavior is not simply redirected as with displacement,
but targeted directly to the issue of concern to the benefit of others
...
Answer: D
...
This behaviorally focused reversal is what undoing is all about
...
Answer: C
...
Bob is still angry, but the recipient of the anger changes
from his wife to another
...
Type A behavior pattern (or the Coronary Prone Behavior Pattern)
a
...
The extreme Type A person is engaged in a chronic struggle to
obtain an unlimited number of things from his environment in
the shortest possible period of time
...
Traits: impatient, competitive, preoccupied with deadlines, and
highly involved with their jobs
d
...
People who get hostile and angry
at everyday slights are more at risk
...
One major prospective study has shown that the Type A behavior
pattern is associated with a twofold increase in incidence of coronary heart disease, even after controlling for the major risk factors
(systolic blood pressure, cigarette smoking, cholesterol)
...
Following a first heart attack, Type As who survived had a lower
chance of a second attack than did Type Bs
...
A study of physically healthy men (Harvard sophomores between 1942
and 1944) followed for nearly 40 years showed that mentally healthy
individuals do not deteriorate in physical health as quickly as do those
in poor mental health
...

2
...
On this scale, different life events contribute different weightings
to the total score
...
The death of a spouse is weighed as the most stressful event

99

USMLE Step 1

l

Behavioral Science and Social Sciences

c
...
30 and +0
...

3
...
The individual’s appraisal of the meaning of the stressor
b
...
Social support

i
...


ii
...


iii
...


iv
...


v
...

4
...
Key stress response pathway: hypothalamic-pituitary-adrenal axis
b
...

c
...
Definition: a general estimate of the functional capacities of the person
2
...
IQ is not an absolute score but a comparison among people
...
Distribution mean: 100; standard deviation: 15

Table 8-1
...
5% of the population

70 to 79

Borderline

80 to 89

Low average

90 to 109

Average

110 to 119

High average

120 to 129

Superior

over 130

Very superior

About 50% of the population

About 2
...
Scaling intelligence: calculating an intelligence quotient
a
...
Mental age (MA) = median test score for a given age

ii
...
Formula: (MA/CA)  100 = IQ score
iv
...

If 25 is the median score of 13-year-olds, then MA = 13,
CA = 10, and (13/10)  100 = 130

100

Chapter 8

l

Psychologic Health and Testing


v
...

b
...
For each age range (cohort), take a sample of the IQ test
scores
...
The mean is 100 and the standard deviation is 15
...
If a child age 10 scores a 25 on the test, find the table for
age 10 and look up a score of 25 to see what IQ level the
score corresponds to
c
...

6
...
IQ is highly correlated with education and is an excellent predictor
of academic achievement
...
Mental illness is distributed across all ranges of intelligence,
although measured IQ may be lower when assessed because of
interference of symptoms
...
Autistic children tend to be of below-average intelligence, with
80% having IQs less than 70
...
Longitudinal tests for intelligence show:

i
...
Verbal ability holds up best

iii
...
IQ is very stable from age 5 onward
...
Increased exposure to verbal behavior early in life leads to a higher IQ
...
IQ tests contain elements of cultural bias, asking about words and
objects more familiar in some cultures than in others
...
Commonly used IQ tests
a
...

b
...

c
...

d
...
Today, it is most useful with children
younger than 6, the impaired, or the very bright
...
Objective tests: simple stimuli (usually questions), restricted range of
responses possible (select between choices given), scored mechanistically using scoring key; no clinical experience required to score
...
Criterion referenced

i
...


ii
...
g
...
“Every student who scores above 75% will pass
...
Norm referenced

i
...

ii
...

l  ost
M
Serves as criterion for newly developed tests
10 primary clinical dimensions and 3 validity
l  ields
Y
scales
2
...
Meaning of responses found by clinical correlation between
collected cases of responses and personal characteristics, psychopathologies
b
...

Rorschach Inkblot Test

l  atients are asked to look at an inkblot and report
P
what they see
...
Thematic Aperception Test (TAT)

l  atients are asked to tell a story about what is going on
P
in the pictures
...
Sentence Completion Test
is asked to complete a set of sentence stems
l  atient
P
with the first thing that comes to mind
iv
...
Halstead-Reitan Battery
a
...
Consists of five basic tests: category test, tactual performance test,
rhythm test, speech sounds perception test, finger oscillation test
...

2
...
Tests level of impairment and functioning
b
...
Bender Visual Motor Gestalt Test
a
...
Nine designs are presented to the patient and copied by him
...
Benton Visual Retention Test
a
...
10 designs that the patient copies as presented or from memory
5
...
Assess memory impairment
b
...
Yields a memory quotient

103

Human Development

9

Learning Objectives
❏❏ Use knowledge of developmental milestones to determine if a child is
developmentally delayed
❏❏ Demonstrate understanding of applying child-development principles
❏❏ List warning signs of child abuse

DEVELOPMENTAL MILESTONES
General Patterns in Human Development
1
...

2
...
e
...
Milestones are simply normative markers at median ages
...
The ages for the milestones are therefore only approximate and
should not be taken as dogma
...
Although children generally progress along the lines of development
together, they often may not
...


Infants
1
...
Evidenced at birth:
a
...
Ability to imitate facial expressions
c
...
Attachment behaviors, such as crying and clinging
2
...
Large, bright objects with lots of contrast
b
...
Curves versus lines
d
...
Evidence of a preference for facial stimuli

105

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Behavioral Science and Social Sciences

3
...

4
...

a
...

b
...

c
...

5
...

6
...
The smile develops from an innate reflex present at birth (endogenous smile)
...
An infant shows exogenous smiling in response to a face at 8 weeks
...
A preferential social smile, e
...
, to the mother’s rather than another’s face, appears about 12 to 16 weeks
...
Physical development
a
...

b
...
Grasp precedes release

ii
...
Proximal to distal progression

iv
...
Capacity to copy shapes follows in alphabetical order:

i
...
The exception is a “diamond,” which can generally not be
reproduced until age 7
...
First words (10 months), then first birthday, then first steps
(13 months)

106

Chapter 9
Figure Copied

l

Human Development

Approximate Age

Circle

3

Cross

4

Rectangle

Square

5

Triangle

6

Diamond

7

Figure 9-1
...
Key developmental issues
a
...
Extending from last trimester of pregnancy through first
14 postnatal months

ii
...
Brain adapts
structure to match environmental stimulation
...
Earliest memories, roughly ages 2–4
c
...
It appears at 6 months, reaches its peak at 8 months,
disappears after 12 months

ii
...
Separation anxiety: distress of infant following separation from a
caretaker

i
...
Begins to disappear at 20–24 months
iii
...

School phobia (Separation Anxiety Disorder) is failure to
resolve separation anxiety
...
Imprinting: an interesting facet of attachment behavior in animals

i
...


ii
...
Does not apply to humans

Table 9-1
...
)
l Alternates feet going up stairs
l Bowel and bladder control
(toilet training)
l Draws recognizable figures
l Catches ball with arms
l Cuts paper with scissors
l Unbuttons buttons
l

Separation anxiety
(12 mo)
l Dependency on
parental figure
(rapproachment)
l Onlooker play
l

Selfish and selfcentered
l Imitates mannerisms
and activities
l May be aggressive
l Recognizes self in
mirror
l “No” is favorite word
l Parallel play
l

Fixed gender identity
l Sex-specific play
l Understands “taking
turns”
l Knows sex and full
name
l

Cognitive Developments (Piaget)

Language Developments

Sensation/
movement
l Schemas
l Assimilation and
accommodation

l

Achieves object
permanence

l

l

l

A world of objects
l Can use symbols
l Transition objects
l Strong egocentrism
l Concrete use of
objects
l

Laughs aloud (4 mo)
Repetitive responding
(8 mo)
l “ma-ma, da-da” (10 mo)
l

Great variation in timing
of language development
l Uses 10 words

Use of pronouns
Parents understand most
l Telegraphic sentences
l Two-word sentences
l Uses 250 words
l Identifies body parts by
pointing
l
l

l

Complete sentences

Uses 900 words
l Understands 4× that
l Strangers can understand
l Recognizes common
objects in pictures
l Can answer, “Tell me what
we wear on our feet?”
“Which block is bigger?”
l

(continued)

108

Chapter 9

l

Human Development

Table 9-1
...
Tanner stages (pubic hair)
Look for

Median ages

1
...
Small amount, downy

10 to 11 years

3
...
Adult-like but not on thigh

13 to 14 years

5
...
Be sure discipline is developmentally age-appropriate
...

b
...

c
...
”
d
...

e
...


Teenagers
a
...
Issues of independence and
self-definition predominate
...
The teenage years may be stressful but are not generally filled with
the type of traumas often portrayed in the popular press
...
Teenagers’ values reflect those of their parents
...
Rebellion is manifested as minor disagreements regarding hair,
music, dress, friends
...
Rebellion is most likely in early teenage years
...
Sexual experimentation with opposite- and same-sex partners is
common
...
In childhood

i
...
Psychologic upset is more easily reversed in stages of
protest or despair than after detachment has set in
...

Because separation has behavioral consequences, pediatric hospitalization must take it into account through
provision of parental contact (e
...
, rooming-in practices,
flexible visiting hours, assurances that mother will be
present when child awakes from surgery)
...
In adults

i
...


ii
...
Intermediate phase (grief, disorganization)
l 3 weeks to 1 year
l Sadness, yearning, somatic symptoms
l Obsessional review, searching for deceased
l May believe they see or hear deceased
l Confronting reality

iv
...
Normal Grief versus Depression
Normal Grief

Depression

Normal up to 1 year

After 1 year, sooner if symptoms severe

Crying, decreased libido, weight
loss, insomnia

Same but more severe

Longing, wish to see loved one,
may think they hear or see loved
one in a crowd (illusion)

Abnormal overidentification, personality
change

Loss of other

Loss of self

Suicidal ideation is rare

Suicidal ideation is common

Self-limited, usually less than
6 months

Symptoms do not stop (may persist for
years)

Antidepressants not helpful

Antidepressants helpful

Dealing with Dying Patients
a
...
Denial
ii
...
Bargaining
iv
...
Acceptance
b
...
Not everyone
passes through all stages or reaches adequate adjustment
...
Similar stages for dealing with loss or separation
d
...
Tell the patient everything
...
Do not give false hope
...
Allow person to talk about feelings
...
Keep involved in activities
...
Avoid social isolation
...
Children do not see the real world, do not live in the same world
that we do
...
They have a limited cognitive repertoire; their thinking is
concrete and egocentric
...
When they become ill, they may interpret this as a punishment and may have misconceptions about what is
wrong with them
...
Children from birth to 5 years old really have no conception of
death as an irreversible process
...
More than death, the preschool child is more likely to fear:

i
...
Punishment

iii
...
Only after age 8 or 9 is there understanding of the universality,
inevitability, and irreversibility of death
...
U
...
population aged 65 or older:

i
...
11
...
13% in 2010
b
...

c
...

d
...

e
...


i
...


ii
...

f
...

a
...

b
...

g
...

h
...


i
...


ii
...


iii
...

i
...


i
...


ii
...


112

Chapter 9



l

Human Development

j
...

k
...

Rates based on <20 deaths
are not shown as they are
statistically unreliable
...
37 suicides per 100,000), and for
females age ≥65 were among the Asian/Pacific Islanders (6
...

l
...

m
...

n
...

o
...
Exercise improves balance and reduces risk of falls in the
elderly
...


ABUSE
Child Abuse
i
...


ii
...


113

USMLE Step 1

l

Behavioral Science and Social Sciences


iii
...
Defining abuse
l  issue damage
T
l Neglect
l  exual exploitation
S
l  ental cruelty
M

v
...

F
l  f case is reported in error, the physician is protected
I
from legal liability
...


vi
...

l  % have no physical signs
...

N
  hey are associated with death or foster home
–T
placement
...


–  f burn is on arms but not hands, it is more likely abuse
...
Children at risk for abuse are
l  ounger than 1 year of age
Y
l Stepchildren
l  remature children
P
l Very active
l “Defective” children
viii
...
Be careful not to mistake benign cultural practices such
as “coining” or “moxibustion” as child abuse
l  hese and other folk medicine practices should
T
usually be accepted
...
Children who are abused are more likely to:
l  e aggressive in the classroom
B
l  erceive others as hostile
P
l  iew aggression as a good way to solve problems
V
l  ave abnormally high rate of withdrawal (girls)
H
l  e unpopular with school peers and other children;
B
the friends they do have tend to be younger
...
150,000 to 200,000 cases of sexual abuse per year
ii
...

iii
...

iv
...

v
...
Most likely source: uncles and older siblings, although
stepfathers are also more likely
vii
...
Risk factors:
l  ingle-parent families
S
l  arital conflict
M
l  istory of physical abuse
H
l  ocial isolation
S
ix
...

l  0% by family members
5
l  0% told no one
5

x
...
Relationship of Child Homicide Victims to Perpetrators

Domestic Partner Abuse



i
...

ii
...


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Behavioral Science and Social Sciences



iii
...
If confronted with a
case, give the victim information about local shelters and
counseling
...
Number of attacks has held steady since mid-1970s
...
Domestic violence is the #1 cause of injury to American
women (for men, traffic accidents and other unintentional injuries are #1)
...
Occurs in all racial and religious backgrounds, and
across all SES groups
vii
...
If one attack occurs, more are likely
...
Male more likely abuser if:
l  onsiders wife his belonging
C
l  e is jealous or possessive
...

T

x
...

l  regnant, last trimester (highest risk)
P

Elder Abuse
i
...


iii
...



Elder abuse is a mandatory reportable offense
...

v
...


Table 9-4
...
 8-year-old girl attains a score of 35 on a standard intelligence test
...
An extract from the table is presented below:

Age
4
5
6
7
8
9
10
11
12

Median Score
15
18
22
25
29
32
35
40
45

Based on this table, the most likely IQ for this 8-year-old girl is
(A) 85
(B) 100
(C) 110
(D) 125
(E) 140
67
...
As a part of the test development
strategy, the results of this observational test are compared with patients’
scores on a standard paper-and-pencil test that also assesses impulse control
...
 55-year-old executive makes a habit of doing several things at once
...
He is impatient with his subordinates and often gets angry with them when they do not perform to his standards or get their work to him on time
...
 5-year-old child is referred to a mental health practitioner for evaluation
...
To accomplish this objective, the practitioner
is most likely to make use of
(A) Luria Nebraska Battery
(B) Halsted-Reitan Battery
(C) Minnesota Multiphasic Personality Inventory
(D) Projective Drawing Test
(E) Rorschach test
(F) Wechsler Intelligence Scale for Children
70
...
His parents become frustrated with his behavior and
ask his physician about the reason for this behavior pattern
...
 5-month-old and a 12-month-old infant observe their mothers leaving
A
the room
...
 young child is able to walk when held by one hand and speaks in strings
A
of unrecognizable words
...
Based on these observations, in the next six to eight months the child is most likely to learn to
(A) ride a tricycle
(B) stand on his tiptoes
(C) draw a circle
(D) build a tower of three blocks
(E) play peek-a-boo

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Human Development

73
...
Based on this evidence, which of the following geometric shapes did the child most recently learn to draw?
(A) Cross
(B) Diamond
(C) Square
(D) Triangle
(E) Circle
74
...
In general, conformity of children to the norms of
their peer groups is most intense at a time of development that also features
(A) toilet training
(B) use of transition objects
(C) focal attachment to the caretaker
(D) beginning of formal schooling
(E) puberty
75
...
In comparison with those undergoing normal development, infants who experience severe psychosocial deprivation are more likely to display
(A) separation anxiety
(B) infantile symbiosis
(C) anxiety with strangers
(D) delayed language development
(E) rapprochement
76
...
Which of the following important behavioral skills are present
in most infants at birth?
(A) Following objects to midline
(B) Laughing aloud
(C) Putting feet into mouth
(D) Reaching and grasping
(E) Recognition of the mother

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77
...
The
A
mother insists that the girl be given a complete physical exam
...
The mother insists that something must
be wrong with the girl because she spends hours playing by herself and talking with a “friend” that no one else can see
...
The physician’s next action should be to
(A) ask the mother about any recent trauma or changes in the girl’s life
(B) reassure the mother that the girl is displaying normal behavior for
her age
(C) re-examine the girl for signs of sexual abuse
(D) schedule the girl for psychiatric evaluation
(E) send the girl for a neurologic consultation
78
...
The girl reports that she had not eaten
in 2 days or seen her mother in the past 24 hours
...
At this point, the physician’s next step would be to
(A) ask the girl if she would like to stay in the hospital for a while
(B) contact the local child welfare agency
(C) contact the police and report the girl’s mother for neglect
(D) initiate IV fluids for the child
(E) obtain permission from the grandmother to begin treatment for
the child
(F) try to contact the girl’s mother
79
...
She reports that she has difficulty sleeping and often finds herself
crying at the “smallest things
...
With some embarrassment, she confesses that she came to see the physician after thinking that
she saw her husband across the street in a crowd, an experience that left her
confused and shaken
...
Answer: D
...
(MA/CA)  100 = IQ
...
Therefore, (10/8)  100 = 125
...
Answer: E
...
Validity means detecting truth
...

68
...
The question presents an example of Type A behavior pattern
...

69
...
The limited verbal skills of the child make this the best choice
...
The Halsted-Reitan and the Luria Nebraska are batteries that assess
and localize brain dysfunction
...
Answer: B
...
This is normal behavior
and not indicative of maladjustment
...

71
...
The key issue here is the timing of separation anxiety
...
The 5-month-old is too young
...

72
...
The child described is about 1 year of age
...
The child should already know peeka-boo, standing on tiptoes is achieved at about 30 months of age, riding
tricycle and drawing a circle are skills learned at about three years of age
...
Answer: A
...
Circle is 3 years of age
...
The other options are for age 6 and up
...
Answer: E
...

75
...
All of these listed are part of normal development with
the exception of delayed language development
...

Rapprochement occurs as the child is learning separation from the parents
...
Answer: D
...
It takes the infant about a week after
birth before it can recognize the mother
...
Answer: B
...
They represent normal developmental patterns and are NOT
indicative of abuse, trauma, or more deep-seated psychological problems
...
Answer: D
...
Care for the patient’s needs first, and then worry about contacting the
appropriate child welfare agency
...
Answer: F
...
She needs reassurance that her reactions,
including “seeing” her husband, are a part of a normal grief process
...


NREM: Non−rapid Eye Movement Sleep
a
...
Alternates with REM sleep throughout the sleep period and is
characterized by:

i
...
Higher muscle tone

iii
...
Absence of “thoughtlike” mental activity
c
...


REM: Rapid Eye Movement Sleep
a
...
An aroused EEG pattern

ii
...
Saccadic eye movements

iv
...
Associated with pons
b
...


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SLEEP

REM

NREM

Stages: 1

2

3

4

Delta sleep
Figure 10-1
...
The sleep-wake cycle itself is a circadian rhythm, i
...
, an endogenous
cyclic change occurs in an organism with a periodicity of roughly
24 hours
...
The cycle is regulated by the superchiasmatic nucleus (SCN)
...
The REM cycle, which is approximately 90 minutes, is an example of an
ultradian rhythm, occurring with a periodicity of less than 24 hours
...
Most of NREM Stages 3 and 4 (the deepest sleep levels) occur during
the first half of the night
...
Stages 3 and 4 together are referred to as delta sleep or slow-wave sleep
...
Most REM sleep occurs during the last half of the night
...

4
...

Adults most commonly wake out of REM or Stage 2 sleep
...
Duration of delta sleep is 65% inherited
...
Sleep latency: period between awake until sleep onset
...
Typically, 5–15 minutes
...
REM latency: period between falling asleep until first REM
...

RL

SL
Awake

124

Sleep

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Sleep and Sleep Disorders

Awake
Stage 1
& REM

Stage 2
Stage 1 sleep and REM sleep (purple)
are graphed on the same level because

...


Delta
1

3

2

4
Hours

5

6

8

7

Awake—low voltage-random fast-beta waves
Fast
Low

Drowsy—8 to 12 cps-alpha waves

Stage 1—3 to 7 cps theta waves
Theta waves

Stage 2—12 to 14 cps-sleep spindles and K complexes
Sleep spindles

K complexes

Delta sleep—1/2 to 2 cps-delta waves>75

REM sleep—low voltage-random, fast with sawtooth waves
Sawtooth Waves

Figure 10-2
...
The cerebral cortex shows the greatest effects of sleep deprivation but
has the capacity to cope with one night’s sleep loss
...
The rest of the body seems relatively unaffected by sleep deprivation
...

3
...

a
...

b
...

4
...
The longer the prior period of wakefulness, the more Stage 4 sleep increases during the first part of the night and the more REM declines
...
Short sleepers lose the latter part of REM sleep
...
In sleep-deprived individuals, the following occurs:
a
...
Cortisol levels rise
c
...
Glucose tolerance is reduced
e
...
Lower prefrontal cortical activity
g
...
REM sleep appears to increase somewhat in both children and adults
after learning, especially the learning of complex material, in the previous waking period
...
REM sleep is essential to get the most out of studying
...

9
...
Does not impede the performance of simple tasks
b
...
Makes it more difficult to learn complex tasks
d
...
Delta sleep increases after exercise and seems to be the result of raised
cerebral temperature
...
Changes in First 3 Hours of Sleep
Human growth hormone (HGH)

Increase

Prolactin

Increase

Dopamine

Decrease

Serotonin

Increase

Thyroid-stimulating hormone (TSH)

Decrease

11
...
Produced in the pineal gland and directly in the retinas of the eyes
b
...
Release is inhibited by daylight, and, at nighttime, levels rise dramatically
d
...
Responsible for “jet lag”
f
...
Adjust melatonin with bright light therapy, not pills

DEVELOPMENTAL ASPECTS OF SLEEP
16
14

Awake

Hours of Sleep

12

50%

10

REM
sleep

25%

8

20%

6
4

NREM sleep

2
0
1:15
days

6:23
mos

2:3
yrs

13:16
yrs

30:50
yrs

90
yrs

Age
Figure 10-3
...
Sleep develops during childhood and adolescence into adult patterns
...
Infants
a
...

b
...

c
...
Mismatch of infant and adult cycles produces “sleep fragmentation” for new parents
...
Adults
a
...
Subsequent cycles
across the evening are shorter
...
REM: 20% of sleep time
c
...

4
...
Total sleep time continues to decline
...
REM percentage remains constant (20%) up to around 80 years of
age, then declines further
...
Stage 4, then Stage 3 NREM (delta sleep) vanish
...


BIOCHEMISTRY OF SLEEP
Chemical and Psychiatric Correlates of Sleep
1
...
Any pharmacology that increases dopamine increases wakefulness
...
Dopamine blockers (e
...
, antipsychotics) increase sleep somewhat
...
Benzodiazepines
a
...
Little rebound effect
c
...

3
...
Moderate

i
...
Increased wakefulness during the second half of the
night
b
...
Decreases REM

ii
...
Barbiturates
a
...
REM rebound, including nightmares, follows stoppage of chronic use
...
Major depression
a
...
Decreases REM latency (45 rather than 90 minutes)
c
...
Increased sleep in multiple periods over 24 hours
e
...
Diurnal improvement
g
...
People who characteristically get a lot of REM are more susceptible to onset of depression

Neurotransmitters Associated with Sleep: “SANDman”
1
...
Acetylcholine (ACh): higher during REM sleep (associated with erections in men)
3
...
Ratio of ACh and NE is the biochemical trigger for REM sleep
...
NE pathway begins in the pons, which regulates REM sleep
...
Dopamine: produces arousal and wakefulness
...

1
...
Sleep attacks and excessive daytime sleepiness (EDS)
b
...
Hypnagogic hallucinations (hypnopompic can occur, but not
pathognomonic)

i
...
Hypnopompic: while waking up
d
...
Narcolepsy is a disorder of REM sleep: onset of REM within 10 minutes
...
Linked to deficiency in hypocretin when cataplexy is present
...

4
...
Modafinil or psychostimulants for excessive daytime sleepiness

i
...
activates glutamate; inhibits GABA
b
...
Gamma hydroxybutyrate (GHB) to reduce daytime sleepiness
and cataplexy

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Sleep Apnea
1
...
Obstructive (upper airway) sleep apnea

i
...
Overweight

iii
...
Central (diaphragmatic) sleep apnea

i
...
Overweight

iii
...
Mixed sleep apnea
2
...
 igh risk of sudden death during sleep, development of severe
H
nocturnal hypoxemia, pulmonary and systemic hypertension
(with elevated diastolic pressure)
b
...
Bradycardia, then tachycardia
d
...
EDS and insomnia often reported
f
...
Kicking, punching of sleeping partner
h
...

Short sleep duration, frequent waking, insomnia, decreased Stage
1, decreased delta and REM
3
...
Weight loss (if applicable)
b
...

Continuous positive airway pressure (CPAP)
...
 or severe obstructive and mixed apnea: tonsillectomy or tracheF
ostomy

Sudden Infant Death Syndrome (SIDS): Unexplained
Death in Children Age <1
1
...
50% reduction in incidence if baby placed on back, rather than on stomach
3
...
Rate is two to three times higher in families where someone smokes
5
...
Fetal exposure to maternal smoking also strong risk factor

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Sleep and Sleep Disorders

Insomnia
1
...
Secondary to hypnotic medication abuse

i
...

Sleep architecture becomes disrupted and sleep fragmentation occurs
...
Emotional problems, especially anxiety, depression, mania
c
...
Withdrawal from drugs or alcohol
2
...
50% of insomnia in sleep labs is due to psychological factors
...
Insomniacs may have GABA levels 30% lower than normal
...
Treatment:
a
...
Behavior therapy still is best (most effective)
...
Muscle relaxation

ii
...
Drugs

i
...
Ramelteon
l Melatonin receptor agonist (MT1, MT2)
l Low chance of dependence
l No hangover or rebound

Night Terrors versus Nightmares

Note

Table 10-2
...


Night Terrors

Nightmares

Sleep stage

Stage 4 (delta sleep)

REM

Physiologic arousal

Extreme

Elevated

Recall upon waking

No

Yes

Waking time anxiety

Yes, usually unidentified

Yes, often unidentified

Other issues

Runs in families

Common from ages 3 to 7

More common in boys

If chronic, likelihood of serious pathology

Can be a precursor to
temporal lobe epilepsy

Desensitization behavior
therapy provides marked
improvement

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Somnambulism (Sleep-walking)
1
...
Stage 4 sleep (Delta)
3
...

4
...
Most seen in Stages 3 and 4 sleep, but can occur in all stages
...
Boys twice as likely as girls
...
Boys cease wetting later
...
Often history with same-sex parent
5
...
Defense mechanism of
regression
6
...


Bruxism (Teeth-grinding)
1
...
Prevention is to use oral device to prevent teeth grinding

132

Physician-Patient Relationship

11

Learning Objectives
❏❏ Demonstrate understanding of general rules of the physician-patient
relationship

GENERAL RULES
Theme: The physician-patient relationship is a potent healing partnership based
on trust
...
The key is what the ideal physician should do
...


a
...


b
...


c
...

Rule #2: Nothing should be between you and patient

a
...
If you must have a table,
Get
pick the smallest one
...
 family members to leave the room
...

Rule #3: Tell the patient everything, even if he or she does not ask
...
Answer any question that is asked
...

Respond to the emotional as well as the factual content of
questions
...

Patient should know what you know and as soon as you
know it
...
 not force a patient to hear bad news if he does not want
Do
it at that moment, but do try to discuss it with him or her as
soon as possible
...
 you have only partial information, say that it is partial and
If
tell what you know
...
We tell them so they tell us
...


g
...


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Rule #4:  ork on long-term relationships with patients, not just short-term
W
problems
...

Each encounter is an opportunity to develop a better relationship
...
Make eye contact
...
Defined touch: tell him or her what you are doing
...
Talk to patient, not colleagues: patient is always the focus
...
Arrange seating for comfortable, close communication
...

Both patient and physician should both be sitting at the
same eye level if at all possible
...


a
...
” You know what matters, but they
Be
don’t
...

Getting the patient to talk is generally better than having the
physician talk
...

Take time to listen to the patient before you, even if other
patients or colleagues are waiting
...
Ask what the patient knows before explaining
...
End encounter by asking, “Is there anything else?”

f
...
Allow silences while patients search for words
Rule #6: Negotiate rather than order
...
reatment choices are the result of agreement, not comT
mands by the physician
...
 emember, the patient makes medical decisions from the
R
choices provided by the physician
...
Relationship and agreement support adherence
...
Look for a “solution,” not the “answer
...
Stay in the room; do not leave
...

Change your plan to deal with new information when it is presented
...
Don’t assume that the patient likes or trusts you
...
 reat difficult or suspicious patients in a friendly, open
T
manner
...


a
...


b
...
Don’t blame it on the nursing staff or on
a medical student
...

Admit the mistake even if it was corrected and the patient is
fine
...


a
...


b
...


c
...
g
...


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Physician-Patient Relationship

Rule #10: Express empathy, then give control: “I’m sorry, what would you
like to do?”

a
...


b
...


c
...


a
...
Ask what patient knows about diagnosis before explaining it

c
...


d
...


e
...

Rule #12:  e sure you understand what the patient is talking about before
B
intervening
...

Patients may present problems with much emotion without
clearly presenting what they are upset about
...
Seek information before acting
...

When presented with a problem, get some details before offering a solution
...
Begin with open-ended questions, then move to closedended questions
...


a
...


b
...
 ake conversations positive
...

Rule #14: Best answers serve multiple goals
...
Think broadly about everything you want to achieve
...
Consider both short- and long-term goals
...

Best answers deal with patients’ health issues, while supporting relationships and acting ethically
Rule # 15: Never lie
...
There is no such thing as a “white lie
...
Do not lie to patients, their families, or insurance companies
...
Do not deceive to protect a colleague
...


a
...
Expect them
...


b
...


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Rule #17: Accept patients’ religious beliefs and participate if possible
...

Your goal is to make the patient comfortable
...


b
...


c
...


d
...

Rule #18: Anything that increases communication is good
...

Take the time to talk with patients, even if others are waiting
...
Ask “why?”

c
...


d
...
Take calls
...

Be
Rule #19: Be an advocate for the patient
...
Work to get the patient what he or she needs
...

Never refuse to treat a patient because he or she cannot pay
...


a
...


b
...


c
...


d
...


MISCELLANEOUS PHYSICIAN-PATIENT RELATIONSHIP
TOPICS
Types of Questions and Statements
a
...
Closed-ended question: limits answer, e
...
, yes or no
c
...
Confrontation: brings to the patient’s attention some aspect of appearance or demeanor
e
...
”
f
...
Direct question: seeks information directly
...


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Components of the Sick Role
a
...
Not to blame for illness
c
...
Obligated to seek competent help
e
...


The Significance of a Good Relationship with the Patient
a
...

b
...

c
...

d
...
The formality of rounds and the imposing
authority that physicians project onto patients may have raised
patient anxiety to dangerous levels
...
The amount of information that surgical candidates receive about
their upcoming operation and about the postsurgical pain affects
outcome
...
Patients given more information about what to anticipate and what they can do about it were ready for discharge 2
...


ii
...

f
...
Fosters adherence to treatment regimens

ii
...
It is not enough for a physician to provide information and treatment and leave adherence to the patient
...

b
...
A
consistent complaint is that insufficient medical information was
made available to the patient (or to the parents)
...


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c
...
Attend to the amount of information

ii
...
Note the patient’s affective state

iv
...
Stress the threat to health of nonadherence

vi
...
Give instructions both orally and in writing
viii
...
Ask patient to do less
d
...
They assume that more of their patients are adhering than actually are
...
When a patient does fail to adhere, do not blame the patient
...
If the patient is nonadherent, check for these problems:

i
...
Misunderstanding of instructions

iii
...
Inability to afford medications
g
...
Adherence is a function of perceived threat
...
Moderate fear level is best for adherence
...


iii
...
External barriers, such as finances or lack of access to
care, can prevent adherence even if perceived threat is
sufficient
...

Psychiatric diagnoses and exogenous pharmacology have long been associated with specific changes in sleep patterns
...
 35-year-old woman complains that she has trouble sleeping at night
...

As he hands her the prescription, he should also caution her that prolonged
use of this class of medications to induce sleep will most likely result in the
appearance of what side effect?
(A) Sleep apnea syndrome
(B) Depressed mood
(C) Insomnia
(D) Nocturnal enuresis
(E) Somnambulism
82
...
K-complexes are characteristic of a stage of sleep also distinguished by
(A) delta waves
(B) theta waves
(C) sawtooth waves
(D) alpha waves
(E) sleep spindles
84
...
A measurable increase in delta stage sleep is often observed following
(A) alcohol intoxication
(B) ingestion of melatonin
(C) medication with imipramine
(D) onset of major depression
(E) physical exercise
86
...
He
A
reports difficulty going to sleep each night, waking up multiple times each
night, and headache upon awaking in the morning
...
Physical exam shows the patient to be 40 pounds overweight
and hypertensive
...
 35-year-old woman goes to see a gynecologist for her first visit on a hot
A
August day
...
The physician introduces himself and shakes
the patient’s hand
...
At this
point, what should the physician say next?
(A) “Boy, it sure is hot out today
...
I have been doing this for years
...
”
(E) “Let me tell you about my credentials and training
...
Tell me a little bit about yourself
...
I won’t hurt you
...
That’s normal at this point
...

Following an annual physical exam, a 43-year-old woman asks her physician for a prescription to cope with anxiety
...
The
physician’s best response would be
(A) ive her the prescription, but ask that her husband schedule an
g
appointment as soon as possible
(B) 
give her the prescription, but instruct her that she should give her husband the medication only if he really needs it
(C) give her a referral for her husband to a local psychiatrist
(D)  ffer to write her husband a prescription if he will call and talk with
o
you on the phone
(E)  ffer to write her husband the prescription after he comes in for a
o
scheduled appointment
(F) refuse to write the prescription
(G) ell her that you will see her husband outside of normal office hours
t
and evaluate the need for the prescription
89
...
The physician’s best response would be
(A) “I’ll speak to the receptionist
...
How can we do better in the
future?”
(C) “It will never happen again
...
”
(E) “Things just take longer with these HMOs
...
What can I do for you?”
(G) “Would you like to come back on another day?”
90
...
Stool samples reveal the presence of Campylobactor
jejuni
...
 56-year-old male executive complains to his physician that he has been
A
having trouble sleeping for the past several months
...
He mentions
that a friend of his was given a prescription for benzodiazapines by his physician for a similar problem, and asks you to give him the same medication
to “make this go away
...
 24-year-old woman is scheduled for delivery by Cesarean section after
A
her unborn child is determined to be wedged in a breech position
...

The physician is not religious and is taken aback by the request
...
Your best advice
would be to tell him to
(A) dvise the patient that her beliefs are not in keeping with modern
a
medical practice
(B) go along with the patient’s request by praying with her and carrying
the charm
(C) politely explain to the patient that he does not share her religious
beliefs
(D)  ray with her and tell her he will carry the charm, but leave it outside
p
the operating theater for sanitary reasons
(E) schedule an appointment for the patient with the appropriate hospital
chaplain
(F) stand in the room as she prays, but decline to carry the charm
(G) 
suggest to the patient that she might be more comfortable with another
physician performing the procedure

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Answers
80
...
Alcohol abuse suppresses REM sleep
...
l-tryptophan decreases sleep latency
...

Anxiety by itself has no demonstrated effect on REM
...

Answer: C
...

82
...
By age 2 to 3 years, about 25% of the child’s sleep time is spent
in REM sleep
...
Stage 4 sleep
is present at birth
...

83
...
Stage 2 sleep is characterized by sleep spindles and K-complexes
...
Theta waves are Stage 1
...

84
...
Human growth hormone and serotonin levels rise during the
first three hours of sleep
...

Answer: E
...

86
...
These symptoms suggest sleep apnea
...

87
...
Take time to find out a little bit about the patient
...

88
...
Do not give a prescription before evaluating the patient
...
(Rule #14 and Rule #1)
89
...
Faced with an irate patient the rule is: express empathy, then
give control
...

Answer: C
...
Discuss the disease before discussing treatment
...

Answer: C
...
Of course you will not give medication just because the
patient asks for it
...

92
...
Rule #17
...


143

Diagnostic and Statistical Manual
(DSM 5)

12

Learning Objectives
❏❏ Demonstrate understanding of applying child-development principles
❏❏ List the major categories of psychiatric disease as defined by DSM5
❏❏ Give examples of disorders within each category, including their
epidemiology, course, and treatment
❏❏ Answer questions about personality disorders

DISORDERS USUALLY DIAGNOSED IN CHILDHOOD
Intellectual Disability
a
...
Down and fragile-X syndromes most common genetic causes

Table 12-1
...
85% of intellectually disabled
...
Usually diagnosed first year in school
...
Sheltered
workshops
...


Profound

Below 20

Needs highly structured environment, constant nursing care, and
supervision
...
Formerly pervasive development disorders
b
...
Clinical signs

i
...
 bnormal or delayed language development, impairA
ment in verbal and nonverbal communication

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Note
Definitions
l

l

l

A
 nhedonia: can’t experience or even
imagine any pleasant emotion
C
 lang associations: illogical
connections by rhythm or puns
D
 elusions: false beliefs not shared
by culture

l

E
 cholalia: repeating in answer many
of same words as in question

l

E
 chopraxia: imitations of
movements or gestures

l

F
 light of ideas: topics strung
together

l

l

l

H
 allucinations: sensory impression,
no stimuli
I
 llusions: misperception of real
stimuli

Loose associations: jump from one
topic to the next

l

 Mannerisms, e
...
, grimacing

l

 Mutism: no speech

l

Neologisms: new expressions


l

Perseveration: responding to all

questions the same way

l

P
 overty of speech: sparse and slow
speech

l

P
 ressured speech: abundant and
accelerated speech

l

V
 erbigeration: senseless repetition
of same words or phrases

146


iii
...
Oblivious to external world

v
...
Pronoun reversal
vii
...
Stereotyped behavior and interests
d
...
Linked to chromosome #15, #11
f
...
Monozygotic concordance greater than dizygotic concordance
h
...

i
...
Association with prenatal and perinatal injury, e
...
,
rubella in first trimester

ii
...
Differential diagnosis

i
...
Autism spectrum disorder without language impairment
(formerly Asperger’s)—language is normal, IQ is normal,
higher level of functioning
k
...
Problems with inattention, impulsivity, hyperactivity
b
...

c
...
Treatment: methylphenidate, dextroamphetamine, atomoxetine

SCHIZOPHRENIA
General Overview
a
...
Bizarre delusions

ii
...
Blunted affect
iv
...
Deficiency in reality testing, distorted perception;
impaired functioning overall

vi
...
> 6 months in duration
b
...

Schizophreniform: if symptoms <6 months

Chapter 12

l

Diagnostic and Statistical Manual (DSM 5)

ii
...
Epidemiology

i
...
Prevalence: 1% of population cross-culturally; however,
less chronic and severe in developing countries than in
developed countries

iii
...
50% of patients attempt suicide, 10% succeed

v
...
Genetic contribution

i
...
Dizygotic concordance: 13%

iii
...
If one parent or one sibling: 12%
v
...
Risk in biologic relatives 10 times general population
(i
...
, 10%)

Clinical Presentation
a
...
DSM-5 does not include subtypes of schizophrenia
...
Paranoid symptoms

i
...
Often accompanied by hallucinations (voices)
c
...

Complete stupor or may have pronounced decrease in
spontaneous movements
be mute
l May

l Often negativism, echopraxia, automatic obedience

l  igidity of posture; can be left standing or sitting in
R
awkward positions for long periods of time

ii
...
Positive symptoms (Type I)

i
...
g
...
Associated with dopamine receptors
b
...
What normals have that schizophrenics do not, e
...
, flat
affect, motor retardation, apathy, mutism

ii
...
Paranoid symptoms
b
...
Quick onset
d
...
No family history of schizophrenia
f
...
Absence of structural brain abnormalities

Neurochemical Issues
a
...
The effectiveness of neuroleptic medications in ameliorating the symptoms of schizophrenia

ii
...
Findings of increased dopamine receptor sensitivity in
postmortem studies

iv
...
Role of serotonin (5-HT)

i
...


ii
...


iii
...
g
...


iv
...

c
...
Major neurotransmitter in pathways key to schizophrenic
symptoms
ii
...

iii
...
Smooth pursuit eye movement (SPEM)

i
...


ii
...

b
...
Faced with a cognitive task, increased activity is found in
the prefrontal cortex of normal individuals
...
Schizophrenics show decreased physiologic activity in
prefrontal lobes when faced with these tasks
...
Impaired performance on the Wisconsin Card Sort
(WCST), a test sensitive to prefrontal dysfunction

iv
...
g
...


Brain Structural and Anatomic Abnormalities
a
...
Larger ventricle size and ventricular brain ratios (VBRs)

ii
...
Smaller frontal lobes

iv
...
Association with specific clinical and cognitive correlates, including deficit symptoms, cognitive impairment,
and poor outcome

l  orrelation between ventricle size, type, and prognosis
C
of illness

l More dilation with negative symptoms

l 
However, dilated ventricles also reported among
patients having unipolar, bipolar, and schizoaffective
disorders (sensitive, but not specific indicator)
b
...
Limbic system seen as the site of the primary pathology
for schizophrenia

ii
...
Antipsychotic medications reduce acute (positive) symptoms in
75% versus 25% with placebo
b
...
40% in 2 years if on medication

ii
...
Prognosis

i
...


ii
...


iii
...
Disorder is when it gets too
long-term or too extreme
...
Mood Disorders

Time

Persistent Depressive
Disorder

Major depression

Alternating

2 yrs

Severe

Stable

Mood

Mild

Cyclothymia

Bipolar (manic-depression)

Basic Subtypes
Persistent Depressive Disorder






i
...
Depressed mood on most days for greater than 2 years
iii
...
Not severe enough for hospitalization
v
...
Alternating states between depressed moods and hypomania
ii
...
Depressive symptoms during months with short or long
days
ii
...
Treat with bright light therapy (not melatonin tablets)


i
...
Must represent a change from previous functioning

iii
...
Suicide:
of depressed patients have suicidal ideation
...

l 15%

v
...
Neurochemical changes

l Decreased norepinephrine

l Decreased serotonin

l Decreased dopamine

l Metabolites of these also decreased
vii
...
Symptoms of major depression plus symptoms of mania:
a period of abnormal and persistent elevated, expansive,
or irritable mood

ii
...
Subtypes

l Bipolar I: mania and major depression

l  ipolar II: major depression plus hypomanic episodes
B

iv
...
Neurochemical changes

l Increased norepinephrine (NE)

l Increased serotonin

vi
...
Most genetic of all psychiatric disorders

Table 12-4
...
Compulsive, rapid ingestion of food followed by compensatory
behavior such as self-induced vomiting, use of laxatives, or exercise: binge and purge
...

b
...
5% males; 5 to 10% of women experience it at some point during their lives
...
Clinical signs:

i
...
Esophageal tears

iii
...
Minimal public eating
d
...
Often associated with girls who previously were obese
f
...
One-third have drug or alcohol problem
...
Treatment: SSRIs, insight, and group therapy

Anorexia Nervosa
a
...
5)
b
...
“Feel fat” even when very thin (body image disturbance)
d
...
Prevalence

i
...
5% of population, 2% of adolescent females

ii
...
95% female
f
...
Predisposing factors

i
...
Mother with history, 50% of susceptibility inherited

iii
...
Treatment

i
...
Full treatment: stabilizing weight, then family and individual therapy
iii
...
Eating Disorders
Anorexia Nervosa

Bulimia Nervosa

Gender

W>M

W>M

Age

Mid-teenage years

Late adolescence/early adulthood

SES

Not specific to high

Not specific to high

Weight

>15% below ideal body weight

Varies, usually nl
...


Neurotransmitters

Serotonin/norepinephrine?

Serotonin/norepinephrine?

Binge/purge

Yes

Yes

Laxative/diuretics

Yes

Yes

Sexual adjustment

Poor

Good

Medical complications

l

l

l

l

Amenorrhea
Lanugo
l High mortality
l Dental cavities
l Electrolyte imbalances

Electrolyte imbalances
Dental cavities
l Callous on hands/fingers
l Enlarged parotid and salivary glands
l Cardiac abnormalities

ANXIETY DISORDERS
1
...
For men,
substance-related disorders are most common
...
Symptoms exhibited more days than not over a 6-month
period (worry about things they do not need to worry
about)
...
Symptoms

l Motor tension (fidgety, jumpy)

l  utonomic hyperactivity (heart pounding, sweating,
A
chest pains), hyperventilation

l  pprehension (fear, worry, rumination), difficulty
A
concentrating

l  igilance and scanning (impatient, hyperactive, disV
tracted)

l  atigue and sleep disturbances common, especially
F
insomnia and restlessness
with SSRI or buspirone
l  reat
T

Panic disorder



154

i
...
No clear circumscribed stimulus; phobic-level reaction,
without a phobic object

Chapter 12

l

Diagnostic and Statistical Manual (DSM 5)


iii
...
Symptoms of a panic attack

l Great apprehension and fear

l Palpitations, trembling, sweating
of dying or going crazy
l Fear

l Hyperventilation, “air hunger”

l Sense of unreality

v
...
5%
to 14% of cardiology patients have panic attacks
l 10

l atients with allergies are 2× more likely to have
P
attacks
...
Can induce panic attacks by hyperventilation, carbon
dioxide, yohimbine, sodium lactate, epinephrine (panicogens)
vii
...
Relapse is common; keep on medication for 6 to 12
months

Phobias

i
...

ii
...
g
...

Social anxiety disorder: fear of feeling or being embarrassed or humiliated

l eads to dysfunctional circumspect behavior, e
...
,
L
inability to urinate in public washrooms, go to restaurants, and speak in public

l  revalence: 1% of general population
P
accompany avoidant personality disorder
l May
with SSRI
l  reat
T
iscrete performance anxiety (stage fright): atenolol or
l D
propranolol (beta blocker)

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OBSESSIVE–COMPULSIVE DISORDER AND RELATED
DISORDERS
Obsessive–Compulsive Disorder
i
...

Compulsion: act which controls the thought, time consuming

iii
...
Epidemiology
have disorder, 3% lifetime prevalence
l 1
...
Increased frontal lobe metabolism

vi
...
Treatment

l SSRIs

Hoarding Disorder
Characterized by persistent difficulty with parting of one’s possessions regardless
of their value
...

Treatment is SSRIs
...

ii
...

iv
...
g
...
May seek multiple plastic surgeries or other extreme
interventions

TRAUMA AND STRESS-RELATED DISORDERS
1
...
Re-experience of the event as recurrent dreams or recollections
(flashbacks)
b
...
Diminished responsiveness to external world
d
...
Irritability, loss of control, impulsivity
f
...
Symptoms must be exhibited for >1 month; if less, diagnose as acute
stress disorder

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Diagnostic and Statistical Manual (DSM 5)

3
...
Most commonly, serious threat to life, family, children, home, or
community
b
...

4
...
g
...
Quicker onset correlates with better prognosis
6
...
Prior emotional variability; excessive autonomic reactions is a
predictor of occurrence
7
...
Prevalence: 0
...
2% in women
9
...
Increased, sustained activity in amygdala
11
...
Decreased cortisol levels
13
...
Treatment: group therapy to facilitate working through normal reactions blocked by disorder
...


SOMATIC SYMPTOM DISORDERS, FACTITIOUS
DISORDER, AND MALINGERING
Somatic Symptom Disorders
Somatic symptom disorder
i
...


ii
...
Onset age <30

iv
...
More common in females than in males (20 to 1)

Conversion disorder (functional neurological symptom disorders)




i
...
Usually skeletal, muscular, sensory, or a peripheral nonautonomic system, e
...
, paralysis of hand, loss of sight
iii
...
Unrealistic interpretation of physical signs as abnormal
ii
...
Preoccupation persists in spite of reassurance
iv
...
prolonged pain
Severe,

ii
...
Pain disrupts day-to-day life

iv
...
Look for secondary gain

T
 able 12-6
...
Some conscious, some unconscious

i
...
Unconscious motivation, therefore, a compulsion
iii
...
Both primary and secondary gain

v
...
g
...
Factitious disorders require treatment; foster relationship and look for motive

Malingering
a
...
Intentional symptom production for gain

ii
...
Symptoms purely for secondary gain, e
...
, to avoid a
court date, military induction, or school

ADJUSTMENT DISORDER
1
...
Criteria:
a
...
Symptoms last <6 months after end of stressor

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Chapter 12

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Diagnostic and Statistical Manual (DSM 5)

c
...
Cannot be a grief response
e
...
Use the defense mechanism of dissociation where you split off a group
of activities or thoughts from the main part of consciousness
2
...
Fugue
a
...
Inability to recall one’s past
c
...
Subtypes (fugue state may appear with all subtypes)
a
...
Dissociative identity disorder (multiple personality)

i
...
Will have lapses in memory
c
...
Recurrent experiences of being detached from or outside
of one’s body—“out of body experiences”

ii
...
Causes significant impairment

PERSONALITY DISORDERS
1
...
Inflexible, inability to adapt
b
...
Lifelong
d
...
Maladaptive patterns of behavior
f
...
Long-standing suspiciousness or mistrust of others: a
base line of mistrust
ii
...
Reluctant to confide in others
iv
...
Carries grudges

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vi
...
Lifelong pattern of social withdrawal, and they like it that
way
ii
...
Restricted emotional expression

Schizotypal



i
...
Magical thinking (including ESP and telepathy), ideas of
reference, illusions

iii
...
Suspiciousness

v
...
Incongruous affect
vii
...
May have short-lived psychotic episodes

Cluster B: Dramatic and Emotional
Histrionic





i
...
Inability to maintain long-lasting relationships
iii
...
Seductive behavior






i
...
Preoccupation with fantasies of unlimited wealth, power,
love
iii
...
Fragile self-esteem, prone to depression
v
...
Genuine surprise and anger when others don’t do as they
want
vii
...
Females two times more than males
ii
...
In constant state of crisis, chaos

Narcissistic






Borderline

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Diagnostic and Statistical Manual (DSM 5)



iv
...
Unstable but intense interpersonal relationships: very
dependent and hostile, love/hate

vi
...
Self-injurious behavior
viii
...
Common defenses: splitting, passive–aggressive

x
...
Often coupled with mood disorder
xii
...
3% males, 1% females
ii
...
Inability to conform to social norms: truancy, delinquency, theft, running away
iv
...
Onset before age 15; if younger than 18, diagnose as conduct disorder

Cluster C: Anxious and Fearful
Behaviors associated with fear and anxiety

Avoidant







i
...
Sees self as socially inept
iii
...
Social isolation, but an intense, internal desire for affection and acceptance
v
...
Tends to stay in same job, same life situation, same relationships

Obsessive–compulsive









i
...
More common in males, firstborn, harsh discipline
upbringing
iii
...
Unable to discard worn-out objects
v
...
Excessively stubborn
vii
...
Wants to keep routine

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ix
...
The anxiety disorder has obsessions and
compulsions that are focal and acquired
...








i
...

iii
...

v
...
Personality Disorders
Definition

Epidemiology

Associated Defenses

Attributes involvement
motives to others, suspicious

1
...
Men > women

Weird, eccentric behavior,
thought, speech

1
...
Women > men

Narcissistic

Grandiose, overconcerned
with issues of self-esteem

Common

Borderline

Instability of mood, selfimage, and relationships

1
...
Common

Paranoid

Schizoid

Schizotypal

Histrionic

2
...
Increased incidence
in families with
schizophrenia

2
...
Underdiagnosed in men

Splitting

2
...
Possible deforming
illness
Dependent

Dependent, submissive

1
...
Women > men

Obssessive-compulsive

162

Perfectionistic and inflexible,
orderly, rigid

1
...
Undoing

2
...
Reaction formation

Chapter 12

l

Diagnostic and Statistical Manual (DSM 5)

Review Questions
93
...
After psychologic testing and an evaluation interview, the boy’s IQ is
assessed at 62
...
 45-year-old woman presents to her primary care physician complaining
A
of fatigue and headaches
...
In addition, she says that she feels sad and worthless
...
 42-year-old woman has always been extremely neat and conscientious,
A
skills she makes good use of as the executive secretary to the president of a
large corporation
...
Although her work is impeccable, she has
few close relationships with others
...
“They just don’t
take the job to heart,” she says disapprovingly about them
...
” The most likely preliminary diagnosis
for this patient is
(A) obsessive–compulsive personality disorder
(B) paranoid personality disorder
(C) schizoid personality disorder
(D) hysterical personality disorder
(E) antisocial personality disorder
(F) narcissistic personality disorder
(G) borderline personality disorder
(H) dependent personality disorder
(I) avoidant personality disorder
(J) schizotypal personality disorder

163

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Behavioral Science and Social Sciences

96
...
When asked the reason for the refusal, he says he
doesn’t see why the physician needs such irrelevant information and eyes
the physician suspiciously
...
 patient’s past medical history indicates numerous admissions to a local
A
public hospital, mostly during the winter months
...

His appearance is disheveled and his clothes are torn
...
” Neurologic examination is unable to uncover
any underlying cause for his reported symptoms
...
 man awakens to find a bright sunny day
...
This behavior
can best be described as
(A) delusion
(B) hallucination
(C) idea of reference
(D) magical thinking
(E) illusion

164

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Diagnostic and Statistical Manual (DSM 5)

99
...
He is
never in any trouble
...
He sits quietly for
hours, rarely talking, and hardly moving, except to ape the movements of
those who pass by him
...

According to twin studies, the strongest evidence of a genetic cause is for
(A) schizophrenia
(B) bipolar disorder
(C) unipolar depression
(D) antisocial personality disorder
(E) alcoholism
101
...
During this time, his positive symptoms have abated
and he shows no signs of relapse
...
 22-year-old intellectually disabled male lives on his own but works in
A
a sheltered workshop setting
...
He meets weekly with a counselor who helps him handle his
money and provides advice about some life decisions
...
 38-year-old woman is brought by her husband to see her primary care
A
physician
...
Physical
exam reveals rapid heartbeat and profuse sweating
...

After some time, she reports that she is tired and has had difficulty sleeping for “what seems like a year, now
...
When questioned about friends, she states
that she just doesn’t see them much any more
...
 42-year-old man who makes his living as a computer programmer and
A
works out of his own home is referred by his employer for evaluation
...
When selected for a company-wide award, he refuses to have his
picture taken for the company newsletter
...
” Although he
is average in appearance, he is convinced that his face is ugly and misshapen
and says that he stays away from people so they “won’t have to look at me
...
 young woman of unknown age is brought by the police to the local emerA
gency department for evaluation after they found her wandering in a local
park
...
Physical exam
shows no abnormalities
...

She is unable to state her name or any details about her life, except that the
name Phoenix seems familiar, although she is not sure why
...
Based on this information, the most likely diagnosis for this patient is
(A) adjustment disorder
(B) amnesia
(C) conversion disorder
(D) depersonalization disorder
(E) dissociative identity disorder
(F) factitious disorder
(G) dissociative amnesia with fugue

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106
...
Her family reports that she suffers from nightmares and violent emotional outbursts when awake
...
The symptoms presented here are
most consistent with a diagnosis of
(A) adjustment disorder
(B) post-traumatic stress disorder
(C) acute stress disorder
(D) dysthymia
(E) major depression
(F) normal grief
107
...
He reports tenderness during palpation, dizziness, and
difficulty concentrating
...
On each previous occasion, no identifiable medical problem could be
uncovered
...
He says that he
knows this is wrong, but he cannot stop himself from doing this
...

Answer: E
...
These individuals live their own lives and make their own decisions, but often need
assistance at some of life’s important transitions points
...

94
...
Starting in the retrolateral part of the pons, this is the major
pathway for norepinepherine
...

95
...
Focusing on details, loving routine, having a sense that there is
only one right way to do things, lack of humor, and few close relationships
suggests an obsessive–compulsive personality disorder
...

Answer: B
...

97
...
The timing during the winter months and the public venue for
the passing out are all suggestive of the secondary gain of malingering
...

Answer: D
...
This is an example
of magical thinking
...

Answer: E
...

100
...
The Heritability Index tells us that about 62% of bipolar disorA
der is due to inheritance
...

101
...
If patients are compliant with medication and make it past the
A
first year without relapse, the chance of relapse is a low 10%
...
 nswer: C
...
He is able to take
A
care of some of his own affairs, but needs weekly help with finances and
works in a sheltered workshop
...
 nswer: B
...
Although some features of other disorders
are present, they do not match criteria
...
 nswer: B
...
All other symptoms arise from this
...
 nswer: G
...

106
...
Avoidance of associated stimuli and nightmares after an identiA
fied traumatic event are the criteria for PTSD
...

107
...
Factitious disorders are characterized by conscious symptom
A
production and unconscious motivation
...
Malingering is a conscious symptom production and
there is clear, conscious secondary gain
...
Definition: multiple motor and vocal tics
a
...

b
...

c
...

2
...
Prevalence is 0
...

b
...

c
...

d
...
Associated with increased levels of dopamine
f
...

g
...
Delirium: acute onset, impaired cognitive functioning, fluctuating and
brief, reversible
2
...
Delirium versus Neurocognitive Disorder
Delirium

Neurocognitive Disorder

History

Acute, identifiable date

Chronic, cannot be dated

Onset

Rapid

Insidious

Duration

Days to weeks

Months to years

Course

Fluctuating

Chronically progressive

Level of consciousness

Fluctuating

Normal

Orientation

Impaired periodically

Disorientation to time → place → person

Memory

Recent markedly impaired

Recent impaired then remote

Perception

Visual hallucinations

Hallucinations, sundowning

Sleep

Disrupted sleep-wake cycle

Less sleep disruption

Reversibility

Reversible

Most not reversible

Physiologic changes

Prominent

Minimal

Attention span

Very short

Not reduced

Neurocognitive Disorders
1
...
5% of population older than 65
b
...
15% of neurocognitive disorders are reversible
...
Primary degenerative neurocognitive disorder of the Alzheimer type
(DAT)
a
...
Memory loss that affects job skills

ii
...
Problems with language

iv
...
Poor judgment

vi
...
Misplacing things
viii
...
Changes in personality

x
...
Epidemiology

i
...
Prevalence increases with age

iii
...
Family history confers greater risk

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Organic Disorders




v
...
Linked to chromosomes 1 and 14 (mutations), 19 (apolipoprotein E), 21 (linked to Down syndrome)
c
...
Unknown

ii
...
Gross pathology

i
...
Flattened cortical sulci

iii
...
Deficient blood flow in parietal lobes correlated with cognitive decline

v
...
Reduced metabolism in temporal and parietal lobes
e
...
Accumulation of amyloid beta-peptides (protein fragment)

ii
...
Neurofibrillary tangles

iv
...
Anatomic changes: to amygdala, hippocampus, cortex,
basal forebrain
f
...
Supportive
ii
...
Reduce environmental changes

iv
...
Donepezil hydrochloride, rivastigmine, galantamine,
memantine
3
...
Definition: decremental or patchy deterioration in cognitive functioning due to severe cerebrovascular disease
b
...
Most prevalent between ages 60 and 70

ii
...
Men > women

iv
...
15% of all neurocognitive disorders in the elderly

vi
...
Etiology

i
...


ii
...
Treatment

i
...
General measures for neurocognitive disorder

Table 13-2
...
Frontal/Temporal disease
a
...
Very rare
c
...
Prominent frontal lobe symptoms (personality change)
e
...
CT or MRI sometimes shows frontal lobe involvement but definitive diagnosis is only at autopsy
5
...
Neurocognitive disorder caused by prion (no DNA or RNA)
b
...
Generally onset between ages 40 and 50
d
...
Fatal in 2 years (usually sooner)
f
...
No treatment
6
...
Autosomal dominant
b
...
Males = females
d
...
Choreoathetoid movements, neurocognitive disorder, psychosis
f
...
Progressive deterioration
h
...
Death in 15–20 years
j
...

7
...
Decreased dopamine in substantia nigra
b
...
Symptoms

i
...
Resting tremor

iii
...
Masklike facies

v
...
Shuffling gait
d
...
Depression is common; treat with antidepressants or electroconvulsive therapy (ECT)
f
...
Wilson disease
a
...
Ceruloplasmin deficiency
c
...
Kaiser-Fleischer rings
9
...
Symptom triad of:

i
...
Urinary incontinence

iii
...
Increased ventricles on CT
c
...
Treat with shunt
10
...
Caused by chronic HIV encephalitis and myelitis

i
...
70 to 95% of patients with AIDS have HIV-related neurocognitive disorder before death
...
Clinically consists of the following:

i
...
Behavioral symptoms: apathy, withdrawal, dysphoric
mood, organic psychosis
iii
...
Average survival from onset to death is 4
...
Early signs of HIV-related neurocognitive disorder: dysphoric
mood, apathy, social withdrawal
e
...
HIV levels in the spinal fluid are good predictors of onset

HEMISPHERIC DOMINANCE
1
...
Language
b
...
Calculation-type problem solving
d
...
Larger in size than is the right side and processes information
faster
2
...
Perception, artistic, visual–spatial
b
...
Stroke damage to right is more likely to lead to apathy and
indifference

APHASIAS
Broca (nonfluent)

Note
l

l

l

l

A
 praxia: loss of ability to learn or to
carry out specific movements, e
...
,
unable to flip a coin when asked to
do so
A
 gnosia: failure to recognize
sensory stimuli, e
...
, visual agnosia,
unable to recognize object when
shown but able to recognize when
touched
A
 lexia: acquired disorder of reading
ability; often accompanied by
aphasia
...
Lesion of frontal lobe (Brodmann area 44)
b
...
Speech production is telegraphic and ungrammatical
...
Often accompanied by depressive symptoms
e
...
Trouble repeating statements
g
...
Lesions of superior temporal gyrus (Brodmann area 22)
b
...
Speech is fluent but incoherent
...
Trouble repeating statements
e
...
No muscle weakness
g
...
Mania-like, rapid speech hyperactivity

Chapter 13

l

Organic Disorders

Conduction (fluent)
a
...
Connection between Broca and Wernicke areas broken
c
...
Trouble repeating statements
e
...
Wide lesions in the presylvian speech area
b
...
Labored telegraphic speech with poor comprehension
d
...
Naming severly impaired

Transcortical
a
...
Capacity to repeat statements is unimpaired
c
...
Dysfunctions on Common Neurologic Exams

175

USMLE Step 1

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Behavioral Science and Social Sciences

Frontal Cortex: Global Orientation
a
...
Speech

ii
...
Abstract thought

iv
...
Capacity to initiate and stop tasks
vi
...
Lesions of dorsal prefrontal cortex

i
...
Decreased drive, initiative

iii
...
Decreased attention

v
...
Broca aphasia (if in dominant hemisphere)
c
...
Withdrawal
ii
...
Explosive mood

iv
...
Violent outbursts

Temporal Cortex
a
...
Language
ii
...
Emotion
b
...
Bilateral lesions: neurocognitive disorder
d
...
Lesions of dominant lobe:

i
...
Auditory hallucinations
iii
...
Thought disorders

v
...
Lesions of nondominant lobe:

i
...
Irritability

iii
...
Key function: intellectual processing of sensory information

i
...
Right: visual–spatial processing (nondominant)
b
...
Agraphia
ii
...
Finger agnosia

iv
...
Dysfunctions in this area account for aproportion of
learning disabilities
c
...
Denial of illness (anosognosia)

ii
...
Neglect of the opposite side (e
...
, not washing or dressing opposite side of body)

Occipital Cortex
a
...
Visual input

ii
...
Destruction: cortical blindness
c
...
Cortical blindness

ii
...
Consists of hippocampus, hypothalamus, anterior thalamus, cingulate gyrus, amygdala
b
...
Key functions

i
...
Memory

iii
...
Reflex arc for conditioned responses

v
...
Sociosexual behaviors
d
...
Apathy
ii
...
Vegetative-endocrine disturbances

iv
...
Hypothalamus
i
...
Regulation of some physiologic responses

l Increased heart and respiration

l  levation of blood pressure and diversion of blood to
E
skeletal muscles when angry

l Regulation of endocrine balance

l Control of eating (hunger/thirst centers)

l Regulation of body temperature

l Regulation of sleep-wake cycle
iii
...
Thalamus

i
...
Dysfunctions lead to impaired memory and arousal
g
...
Motivation
ii
...
Wakefulness
h
...
Lesions and Memory
Lesion

Short-Term Memory

Long-Term Memory

New Learning

Medial temporal lobe

Spared

Spared

Impaired

Hippocampus

Spared

Impaired

Impaired

i
...
Dorsomedial portion of temporal lobe

ii
...
Direct link between limbic system and motor system
iv
...
The “unconscious mind”?
vi
...

Korsakoff syndrome

l Amnesia resulting from chronic thiamin deficiency

l Associated with alcoholism

l Neuronal damage in the thalamus
nce neuronal damage in the thalamus, not treatable
l 
O
with thiamin

Basal Ganglia
a
...
Dysfunctions (see Neurocognitive Disorder section)

i
...
Huntington chorea

iii
...
Fahr disease
hereditary disorder
l Rare

l Calcification of the basal ganglia

l Onset at age 30

l Neurocognitive disorder at age 50

l Resembles negative symptom schizophrenia

Pons
a
...
Important for REM sleep
c
...
Key for balance
b
...
Facilitates verbal recall
d
...
Neurotransmitter at nerve-muscle connections for all voluntary muscles of the body
2
...
Despite long history, the exact role of ACh in the brain unclear
4
...
Significant role in Alzheimer disease
6
...
Associated with erections in males
8
...
In the corpus striatum, ACh circuits are in equilibrium with dopamine
neurons
...
One of the catecholamine neurotransmitters
2
...
Acceleration of the heart
b
...
Elevation of blood pressure
3
...
Key pathway: locus ceruleus in upper pons
5
...
Depletion of NE leads to depression
b
...
Based on two observations:

i
...


ii
...

6
...
Alpha-1: sympathetic (vasoconstriction)
b
...
Beta-1: excitatory for heart, lungs, brain
d
...
The other catecholamine neurotransmitter
2
...
D2 receptors most important
4
...
D2, D3, and D4 inhibit G-protein and decrease cAMP and excitation
6
...
Nigrostriatal pathway
l 
Blockade leads to tremors, muscle rigidity, bradykinesia
b
...
Tuberoinfundibular system
l 
Blockade leads to increases in prolactin (Dop = PIF)

180

Chapter 13

l

Organic Disorders

Serotonin (5-hydroxytryptamine, 5-HT)
1
...
Changes in the activity of serotonin neurons are related to the actions of
psychedelic drugs
...
Involved in the therapeutic mechanism of action of antidepressant
treatments (most are 5-HT re-uptake inhibitors; a few new ones are
5-HT agonists)
4
...
Low 5-HT = low impulse control
6
...
One of the major amino acids in general metabolism and protein synthesis, also a neurotransmitter
2
...
The neurotransmitter of the major neuronal pathway that connects the
cerebral cortex and the corpus striatum
4
...
Evidence that glutamic acid is the principal neurotransmitter of the visual pathway
6
...
Reason for PCP symptoms (antagonist of NMDA glutamate receptors)
8
...
Composed of two peptides, each containing five amino acids
2
...
Neurons are localized to areas of the brain that regulate functions influenced by opiate drugs
...
Peptide containing 11 amino acids
2
...
Also found in numerous brain regions
4
...

5
...
One of the amino-acid transmitters in the brain
2
...
Reduces the firing of neurons; principle inhibitory neurotransmitter in
the brain
4
...
Quantitatively, the predominant transmitter in the brain
6
...
Treatment concerns
a
...
Most common reason for failure of treatment is inadequate dosage
c
...
Common uses
a
...

b
...
Movement disorders: Tourette, Huntington, and hemiballism
(flailing movements)
d
...
Intractable hiccups
f
...
Mechanisms of action
a
...
Alpha-adrenergic blockade; therefore, hypotensive effect
c
...
Blocks both NE re-uptake and serotonin and histamine receptors
4
...
Neurologic effects
i
...
effects: from antagonism of H1 receptors
CNS

l Weight gain

l Sedation very common

l Impaired memory
iii
...
Extrapyramidal Reactions to Antipsychotic Medications
Side Effects

Peak

Dystonic reactions (jerky movements, trouble speaking)

1 week (younger are more at risk)

Akinesia

2 weeks

Rigidity

3 weeks

Tremors

6 weeks

Akathisia

10 weeks

Pisa and Rabbit syndromes

18+ weeks

iv
...
Non-neurologic effects
i
...

Particular taste (also dental cavities)
iii
...
effects: prolactin elevated
Sexual
en: decreased libido, inhibition of ejaculation, retrol 
M
grade ejaculation
omen: breast enlargement and lactation, changes in
l 
W
libido
v
...
Potency of Antipsychotic Medications
Potency

Extrapyramidal Symptoms

Anticholinergic Effects

High (haloperidol)

High

Low

Low (chlorpromazine)

Low

High

Table 14-3
...
Short- and long-acting preparations
ii
...
Retinitis pigmentosa
ii
...

Weak reaction on D2 receptors
ii
...

Affects negative and positive symptoms
iv
...

Less incidence of EP, TD, prolactin, or sexual effects

185

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Behavioral Science and Social Sciences

Risperidone (Atypical)




i
...

Side effects: dizziness, fatigue, dry mouth, tachycardia,
hypotension
iii
...

A
 ffects positive and negative symptoms, thought disorders

ii
...


Quetiapine (Atypical)






i
...

iii
...

v
...
Partial agonist on D2 and 5-HT1 receptors
...

ii
...
Also used for bipolar and adjunt therapy for depression
iv
...
High affinity for DA, 5-HT, alpha-adrenergic, and histamine receptors
ii
...
For acute agitation of psychoses, acute mania
iv
...
Prolongs QT interval

ANTIDEPRESSANTS
General Issues
Common uses
a
...
Anxiety
c
...
Action: blocking of re-uptake of serotonin and norepinephrine,
blocking of alpha-1 adrenergic receptors, and muscarinic receptors
...
Pharmacokinetics

i
...
Metabolized by the liver and excreted by the kidneys

iii
...
Adverse effects
i
...
effects
CNS

l Drowsiness

l Insomnia and agitation

l Disorientation and confusion

l Headache
tremor
l Fine
iii
...

Sexual
impotence, testicular swelling
l Men:
omen: anorgasmia and breast enlargement (treat
l 
W
with cyproheptadine)
v
...
Cautions

i
...
Not for patients with respiratory difficulties; dries up bronchial secretions

iii
...
May impair driving

v
...
Manic episode induced in 50% of bipolars
vii
...
Baby gets 1% of mother’s dose in breast milk
f
...
After prolonged use, should be gradual

ii
...
Most widely used antidepressants
b
...
Fewest adverse effects of any antidepressants currently available,
also the largest selling

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Behavioral Science and Social Sciences

d
...

Anorgasmia and delayed orgasm in 15 to 20% of patients
ii
...
Drugs from this class

i
...
Sertraline
iii
...
Fluvoxamine: approved for OCD

v
...
Escitalopram

Monoamine oxidase inhibitors (MAOIs)
a
...
Inhibits MAO, an enzyme that metabolizes serotonin,
epinephrine, and NE

ii
...
Adverse effects

i
...
Depression (80%)
b
...
Bipolar disorder

Mechanism of action
a
...

b
...
Usually requires 5 to 10 treatments
d
...
g
...
Memory loss and headache common, returns to normal in several
weeks
b
...
Although not usually first-line treatment, should be considered for:

i
...
Depressed pregnant patients
b
...
5-HT receptor antagonist, alpha-1 blocker
b
...

Sedating, but effective at improving sleep quality, does not decrease
Stage 4 sleep
d
...
Stimulates NE and 5-HT release
b
...

Side effects: somnolence (60%), increased appetite, weight gain

Bupropion
a
...
No anticholinergic effect
c
...
Increased risk of seizures
e
...

Side effects: appetite suppressant, agitation, insomnia
g
...

Inhibits reuptake of NE and 5-HT, mild dopamine effect (SNRI)
b
...
Targets 5-HT and NE receptors (SNRI)
b
...
Approved for depression and neuropathic pain

189

USMLE Step 1

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Behavioral Science and Social Sciences

MOOD STABILIZERS
Lithium
a
...
Works for 70% of cases
c
...
Pharmacokinetics:

i
...
Requires reaching plasma levels very close to toxic levels
for effect, which is reached in 10 to 14 days

iii
...
8–1
...
4

l  rank toxicity at 2
...
5 = hemodialysis
F

iv
...
Peak serum level: 1–3 hours

vi
...

e
...
Narrow margin of safety, must monitor blood levels

ii
...
Seizures and coma

iv
...
Edema
vi
...
Benign leukocytosis
viii
...
Nephrotoxic

x
...
Long-term lithium use has adverse effects on renal function
...
Compliance often difficult, patient may value manic experiences
h
...
For acute mania, rapid cycling bipolar disorder, impulse control
b
...
Monitor blood levels
d
...
Side effects

i
...
Mild tremor

iii
...
Occasional agranulocytosis
f
...
Teratogenic (neural tube defect)

Carbamazepine: Second-line Treatment
a
...
Mechanism of action:

i
...
Alters central GABA receptors
c
...
Side effects

i
...
Occasional agranulocytosis

iii
...
Toxic levels: atrioventricular block, respiratory depression, coma

ANXIOLYTICS (ANTIANXIETY)
Benzodiazepines
a
...
Mechanism of action: depresses CNS at limbic system, RAS, and
cortex
c
...
Pharmacokinetics

i
...
Well-absorbed orally
e
...
CNS depression (sedative effect)

ii
...
Confusion and disorientation, especially in elderly

iv
...
Withdrawal: insomnia, agitation, anxiety rebound, gastrointestinal distress; abrupt withdrawal can bring on seizures
f
...
Lowers tolerance to alcohol

191

USMLE Step 1

l

Behavioral Science and Social Sciences

h
...
Passed on in breast milk with observable effects
j
...
anxiety
For

ii
...

Affects serotonin, not GABA

iv
...
Some sedation

vi
...
No withdrawal effects
viii
...

Following his arrest for disturbing the peace, a 35-year-old man is referred
for psychiatric evaluation
...
He reported that he had slept little in the
past few days, but that he felt “great”
...

“Sometimes I just feel so bad I can hardly move
...
 36-year-old woman is brought to see her physician by her family
...
Symptoms include frequent and discrete brisk movements
that cause jerks of the pelvis and limbs as well as facial frowns, grimaces,
and smirks
...
 ver a 5-week period, a previously healthy 55-year-old female has develO
oped headaches, progressively severe word-finding difficulty, and confusion
...
What is the most likely site of the lesion?
(A) Frontal lobe
(B) Temporal lobe
(C) Occipital lobe
(D) Parietal lobe
(E) Cerebellum
111
...
Over the next week, his medical
record notes the appearance of auditory hallucinations, delusions, thought
disorders, and poor verbal comprehension
...
 32-year-old male presents at the local clinic complaining of abdominal
A
cramps, sweating, runny nose, vomiting, and muscle aches
...
He states that he “feels
just awful” and that he has had these symptoms for about 24 hours
...
 58-year-old chronic alcoholic is evaluated and found to have difficulty
A
with recall of recent events although long-term memories seem intact
...
These symptoms are the result of a syndrome
that can result from neuronal damage to the
(A) cerebellum
(B) hippocampus
(C) hypothalamus
(D) reticular activating system
(E) thalamus
114
...
This medication has been very
effective at controlling his delusions and hallucinations
...
The patient reports that it is hard to read because his vision
is blurry, and then lapses into delirium
...
 24-year-old woman was recently diagnosed with undifferentiated schizoA
phrenia and placed on a standard drug regimen
...
The
most likely side effect to appear at this time would be
(A) akathisia
(B) akinesia
(C) physical tremors
(D) Pisa syndrome
(E) tardive dyskinesia

194

Chapter 14

l

Psychopharmacology

116
...
 46-year-old man who was being treated for depression is brought to the
A
emergency department complaining of headache at the base of the skull,
chest pains, and stiff neck
...
He reports
vomiting repeatedly in the past few hours
...
Answer: D
...

109
...
Age of onset and description indicate the onset of Huntington
chorea
...
Answer: B
...

111
...
Lesions of the dominant temporal lobe result in euphoria,
auditory hallucinations, thought disorder, and poor verbal comprehension
...
Answer: D
...
The drug on the
list to treat the withdrawal is clonidine
...
Answer: E
...

114
...
The patient displays the symptoms of anticholinergic intoxication
...

115
...
Difficulty completing simple movements or common skills
occurs relatively early in the course of treatment
...
Tardive dyskinesia rarely occurs before
the patient is on the medication for at least 3 months
...
Answer: A
...

117
...
The patient is suffering from a hypertensive crisis that is likely
the result of consuming tyramine-containing food while on MAOIs for his
depression
...


196

Ethical and Legal Issues

15

Learning Objectives
❏❏ Demonstrate understanding of selected important court cases
❏❏ Differentiate between legal issues and ethical issues as they are related to
medical practice

SELECTED IMPORTANT COURT CASES
Karen Ann Quinlan: Substituted Judgment Standard
In the Quinlan case, Karen Ann was in a persistent vegetative state, being
kept alive only by life support
...
The
court found that “if Karen herself were miraculously lucid for an interval 
...
”
The court therefore allowed termination of life support, not because the
father asked, but because it held that the father’s request was most likely the
expression of Karen Ann’s own wishes
...
In this case,
however, the patient is unable to decide, and a decision-maker who is the
best representative of the patient’s wishes must be substituted
...
Therefore, the
decision is made for the patient on the basis of the best estimate of his or her
subjective wishes
...


197

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Behavioral Science and Social Sciences

SELECTED IMPORTANT COURT CASES (Continued )
Brother Fox (Eichner vs Dillon): Best Interest Standard
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
...

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
...
The object of the standard is to decide what a hypothetical
“reasonable person” would decide to do after weighing the benefits and
burdens of each course of action
...
All persons
applying the best-interest standard should come to the same conclusions
...
Yet, in this exceptional case they did
...
The infant’s parents were informed that surgery to
correct his fistula would have “an even chance of success
...

The parents, who also had two healthy children, chose to withhold food and
treatment and “let nature take its course
...
The court denied such action, and
the Indiana Supreme Court declined to review the lower court’s ruling
...
S
...

Note that this case is simply an application of the best-interest standard
...


198

Chapter 15

l

Ethical and Legal Issues

SELECTED IMPORTANT COURT CASES (Continued )
Roe vs Wade (1973): The Patient Decides
Known to most people as the “abortion legalizing decision,” the importance of
this case is not limited to its impact on abortion
...

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
...

Note that courts have held that a pregnant woman has the right to refuse care
(e
...
, blood transfusions) even if it places her unborn child at risk
...
When he leaves, the counselor is concerned enough
to call the police but takes no further action
...
The court found the counselor and the center liable
because they did not go far enough to warn and protect the potential victim
...

In similar situations, first try to detain the person making the threat, next call the
police, and finally notify and warn the potential victim
...


LEGAL ISSUES RELATED TO MEDICAL PRACTICE
This section lays out a set of rules that constitute the general consensus of legal
opinion
...

Rule #1: Competent patients have the right to refuse medical treatment
...

l Patients have an almost absolute right to refuse
...
The sicker the patient, the lesser
the chance of recovery, the greater the right to refuse treatment
...

l Advance directives can be oral
...

l

Rule #3: Assume that the patient is competent unless clear behavioral evidence
indicates otherwise
...

l A diagnosis, by itself, tells you little about a patient’s competence
...
The patient does not
have to prove to you that he is competent
...


Note
Family matters only to the degree that
reflects the patient’s wishes
...


Rule #4: When surrogates make decisions for a patient, they should use the following criteria and in this order:
l Subjective standard
l Actual intent, advance directive
l What did the patient say in the past?
l Substituted judgment
l Who best represents the patient?
l What would patient say if he or she could?
l Best-interest standard
l Burdens versus benefits
l Interests of patient, not preferences of the decision-maker
Rule #5: Feeding tube is a medical treatment and can be withdrawn at the
patient’s request
...

l A competent person can refuse even lifesaving hydration and nutrition
...

l Active euthanasia and assisted suicide are on difficult ground
...
e
...
e
...
g
...

Rule #7: The physician decides when the patient is dead
...

l If there are no more treatment options (the patient is cortically dead),
and the family insists on treatment, there is nothing the physician can
do; treatment must stop
...

l Lack of financial resources or lack of results are never reasons to stop
treatment of a patient
...

l You can not ever threaten abandonment
...

l Intimate social contact with anyone who is or has been a patient is prohibited
...
”
l Do not date parents of pediatric patients or children of geriatric patients
...

l Do not prescribe for colleagues unless a physician/patient relationship
exists
...

l Any gift from a patient beyond a small token should be declined
...

l Take whatever action is required to prevent harm
...

l You must also protect your patient, or anyone not your patient, from
being hurt by another
...

l Full, informed consent requires that the patient has received and understood five pieces of information:
l Nature of procedure
l Purpose or rationale
l Benefits
l Risks
l Availability of alternatives
l Four exceptions to informed consent:
l Emergency
l Waiver by patient
l Patient is incompetent
l Therapeutic privilege (unconscious, confused, physician deprives
patient of autonomy in interest of health)
l Gag clauses that prohibit a physician from discussing treatment options
that are not approved violate informed consent and are illegal
...

l A signed paper the patient has not read or does not understand does
NOT constitute informed consent
...


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Behavioral Science and Social Sciences

Rule #12: Special rules apply with children
...

l Exceptions: emancipated minors
l If older than 13 years and taking care of self, i
...
, living alone, treat
as an adult
...

l Pregnancy or giving birth, in most cases, does not
...

l If parents refuse permission to treat child:
l If immediate emergency, go ahead and treat
...
g
...

l If not life- or limb-threatening (e
...
, child needs minor stitches),
listen to the parents
l Note that the child cannot give permission
...

Rule #14: For the purposes of the USMLE, issues governed by laws that vary
widely across states cannot be tested
...

Rule #15: Good Samaritan Laws limit liability in nonmedical settings
...

l Physician remains at scene after starting therapy until relieved by
competent personnel
l No compensation changes hands
Rule #16: Confidentiality is absolute
...

l Physician must strive to ensure that others cannot access patient information
...
However, watch the location of the consultation
...
g
...


202

Chapter 15

l

Ethical and Legal Issues

If you receive a court subpoena, show up in court but do not divulge
information about your patient
...

l Infectious disease should generally be treated as a threat, but be
careful
...
Best advice: Have
patient and partner come to your office
...

l DNR refers only to cardiopulmonary resuscitation
...

l Most physicians are unaware of DNR orders
...

l Have DNR discussions as part of your first encounter with the patient
...
Explain details
of what is entailed
...

l Committed mentally ill adults legally are entitled to the following:
l They must have treatment available
...

l They can command a jury trial to determine “sanity”
...

l They retain their competence for conducting business transactions,
marriage, divorce, voting, driving
l The words “sanity” and “competence” are legal, not psychiatric, terms
...

Rule #19: Detain patients to protect them or others
...

l A physician can detain; only a judge can commit
...
Children can be committed only if:
l They are in imminent danger to self and/or others
...

l The parents have absolutely no control over the child, and the child
is in danger (e
...
, fire-setter), but not because the parents are unwilling to discipline a child
...

l Types of risks
l Infectious disease (TB)
l Substance-related disorders
l Depression (or other psychological issues)
l Incompetence
l Actions
l Insist that they take time off
l Contact their supervisors if necessary
l The patient, not professional solidarity, comes first
...

The best answers are those that are both legal and ethical
...
If
patient may react negatively, figure out how to tell patient to mitigate negative
outcome)

What if the family requests that certain information be kept from the patient? (Tell the patient, but first find out why they don’t want the patient told)

Who owns the medical record? (Health care provider, but patient must be
given access or copy upon request)

What should the physician do in each of these situations?
l

l

l

l

l

l

204


Patient refuses lifesaving treatment on religious grounds? (Don’t treat)

Wife refuses to consent to emergency lifesaving treatment for unconscious
husband citing religious grounds? (Treat, no time to assess substituted judgment)

Wife produces card stating unconscious husband’s wish to not be treated on
religious grounds? (Don’t treat)

Mother refuses to consent to emergency lifesaving treatment for her daughter on religious grounds? (Treat)

What if the child’s life is at risk, but the risk is not immediate? (Court takes
guardianship)

From whom do you get permission to treat a girl who is 17 years old? (Her
guardian)

Chapter 15

l

Ethical and Legal Issues

From whom does the physician obtain consent in each case?
l

l

 17-year-old girl’s parents are out of the country and the girl is staying with
A
a babysitter? (If a threat to health, the physician can treat under doctrine of
in locum parentis)
A 17-year-old girl who has been living on her own and taking care of herself?
(The girl herself)

l

 17-year-old girl who is married? (The girl herself)
A

l

 17-year-old girl who is pregnant? (Her guardian)
A

l

l

l

 16-year-old daughter refuses medication but her mother consents, do you
A
write the prescription? (Yes)
 16-year-old daughter consents, but the mother refuses? (No)
The
 mother of a minor consents, but the father refuses? (Yes, only one perThe
mission needed)

l


When should the physician provide informed consent? (Always)

l


Must informed consent be written? (No)

l


Can written consent be revoked orally? (Yes)

l

l


Can you get informed consent from a schizophrenic man? (Yes, unless there
is clear behavioral evidence that he is incompetent)

Must you get informed consent from a prisoner if the police bring in the
prisoner for examination? (Yes)

205

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Behavioral Science and Social Sciences

Review Questions
118
...

The girl has sustained a non-life-threatening but serious injury during play
that has almost completely severed one of her fingers from her left hand
...

Without prompt action, the use of the finger is likely to be lost
...
The best course of action would be to
(A) try to contact the parents to get their permission to perform the
procedure
(B) seek a legal injunction allowing the operation
(C) operate at once, citing the doctrine of therapeutic privilege
(D) seek the consent for the operation from the woman in whose care the
girl was left
(E) seek further confirmation from additional specialists in this type of
surgery
119
...
When you mention your concern to the resident,
he tells you, “Mind your own business
...
” At this
point, your best action would be to
(A) 
monitor the chief resident over the next few weeks to be sure that there
is no danger to patient care
(B) talk with other residents and see if they share your concern
(C) contact the hospital ethics committee for advice and guidance
(D) contact the American Medical Association
(E) seek legal counsel
(F) schedule a meeting to speak with the residency program director
(G) lodge a complaint with the state licensing board
(H) ask the nursing staff if they have noticed anything unusual about the
chief resident

206

Chapter 15

l

Ethical and Legal Issues

120
...
The
case involves a 45-year-old male who received a lymph node biopsy
...
However, during the procedure, the resident performing
the surgery nicked the large intestine
...
The resident was overheard to say, “It’s all taken care of
...
” After
overhearing this conversation, what action should the physician take?
(A) Ask the nurse for the patient’s chart to confirm that the mistake was benign
(B) File a formal complaint with the hospital ethics committee
(C) File a formal complaint with the state licensing board
(D) Look up the patient and check on how he is doing
(E) Reprimand the residents on the spot and demand to speak with their
supervisor
(F) No harm was done, the physician need do nothing
(G) Speak with the chairman of internal medicine
(H) Speak with the chairman of surgery
(I)  the residents that they need to inform the patient and suggest the
Tell
best method to have the discussion
121
...
She announces with great excitement that she will be getting married
in 3 months and invites her physician to attend the wedding
...
At this
point, what action should the physician take?
(A) Call the patient immediately and inform her of the findings of the
mammogram
(B) Have a nurse with experience in this area call the patient and discuss
the findings
(C)  ake an appointment to discuss the mammogram finding with the
M
patient within a week of receiving the results
(D)  ostpone informing the patient of the findings until after the wedding
P
so as not to upset her
(E) Schedule the patient for a confirmatory mammogram after the wedding
(F) 
Schedule an appointment to discuss the findings with the patient and
her fiancé before the wedding

207

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Behavioral Science and Social Sciences

122
...
The physician provides encouragement with his diet
and adjusts his medication dosage
...
What action should the physician take?
(A) Have the nursing staff call her back and explain the dietary regime
(B) Give her an internet address where information about diabetes can be found
(C) Obtain permission from her husband before discussing his diabetes with her
(D) Schedule an appointment to discuss the issues she raises face-to-face
(E) Ask her if her husband requested that she call
(F) Offer her a referral to another physician so she can be checked for diabetes
123
...
The standard procedure for such cases is by-pass surgery that has
a high rate of success
...
Life expectancy for the pharmacologic intervention is substantially shorter than the surgical one
...
The physician
strongly disagrees with the patient’s decision
...
A 54-year-old man, who makes his living as a bus driver, was sent by his
company for a physical exam
...
When questioned in detail,
the man professes no difficulty going to sleep
...
He also reports hallucinations as he is falling
asleep and sometimes is unable to move when he wakes up in the morning
...
When
informed of this diagnosis, the patient requests that this information be
kept confidential from his employer
...
A 66-year-old man recently diagnosed as having prostate cancer is scheduled for an appointment to discuss his treatment options
...
The resident
meets with the patient and returns with signed informed consent forms,
indicating that the patient has elected the radiation option to treat his
cancer
...
At this point, what action should
the attending physician take?
(A)  onvene a seminar of all residents in this rotation and review the
C
informed consent rules
(B) 
Exclude the resident from obtaining informed consent from patients
until he has reviewed the informed consent rules
(C) 
Have all of the residents on the rotation accompany you while you visit
the patient and demonstrate the right way to obtain informed consent
(D)  nformed consent has been obtained, but instruct the resident that in
I
the future he should mention the surgical procedure as an option to
the patient
(E) nformed consent has been obtained; schedule the patient for the
I
radiation treatment to which he has consented
(F) 
Instruct the resident to go back and talk to the patient again, this time
mentioning the new surgical procedure
(G)  isit the patient personally and obtain informed consent again, this
V
time mentioning the new surgical procedure

209

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Behavioral Science and Social Sciences

Answers
118
...
The physician may exercise therapeutic privilege and assume in
A
locum parentis responsibility
...
 nswer: F
...

120
...
The dual goals of training the residents and making sure the
A
patient gets the information need to be met here
...

121
...
You need to deliver the bad news, in a timely manner, and in
A
person
...
 nswer: C
...
You are not to discuss the case with
A
her without the husband’s explicit permission
...
 nswer: E
...
The
A
options and consequences have been explained and the patient has made
his choice
...
Note that the surgical option is still available
should the patient change his mind
...
 nswer: C
...
There
is a clear risk, so confidentiality must be breached to prevent harm
...
The physician is obligated to act
...
 nswer: F
...
The resident should complete the job he started and go
back to talk to the patient again
...


210

Health Care Delivery Systems

16

Learning Objectives
❏❏ Answer questions about government and nongovernment methods of
payment for services

NONGOVERNMENT METHODS OF PAYMENT FOR
SERVICES
a
...

Economic incentive is to do more so more can be billed
...
Physicians make money when more treatment is provided
...
Danger = overtreatment
b
...
Insurance company helps patient pay for health care in
exchange for a periodic payment by patient (premium),

ii
...
Patient 20%/insurance 80% or
2
...
Cross Blue Shield: nonprofit insurance company
Blue
Cross covers hospital charges
l Blue
Shield covers physician services
l Blue

l Coverage comes with deductibles and copayments

211

USMLE Step 1

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Behavioral Science and Social Sciences


l Premiums intended to cover only:
–
Benefits
–
Administrative costs
–
Catastrophic losses
c
...
Either hires physicians or contracts with physicians to
provide services

ii
...


l  hysicians are paid for the number of patients they
P
are responsible for, not for how much they do for each
patient
...

o additional (or only minimal) payment is made
l 
N
when services are used
...


l Incentives:
–
Under treatment
– More likely to foster preventive medicine

Appendix Table 1
...
Preferred provider organization (PPO): fee-for-service at a discount
i
...
Discount is substantial, often 30% below standard fees for
primary care and 50% below standard fees for specialists
iii
...
Provider makes money on volume, i
...
, less money per
patient but more patients
...


v
...


vi
...


212

Chapter 16



l

Health Care Delivery Systems

vii
...


GOVERNMENT METHODS OF PAYMENT FOR SERVICES
a
...
Program pays health care costs for the:

l Elderly (age >65)

l Disabled

l Dependents of disabled

ii
...

iii
...


iv
...


v
...


vi
...

Some prescription coverage is available for an added fee
...
Services not covered: routine physicals; eye/ear examinations for glasses/hearing aids; immunizations; routine foot
care; custodial (nursing home) care; most self-administered drugs
...
Medicaid: health care payments for those on welfare

i
...
Covers all care, including hospital stays, physician services, medication, and nursing homes
...

iii
...
No deductibles, copayments, or fees

v
...

c
...
DRGs have been used in the United States since the
early 1980s to determine how much Medicare pays the hospital
for services
...


213

USMLE Step 1

l

Behavioral Science and Social Sciences




i
...
Prospective payment is set by taking national median cost
to treat each of approximately 500 different diagnoses
...
Payment is determined by adding or subtracting from
this median cost according to a formula that includes:

l Principal and up to four secondary diagnoses

l Principal procedures

l Patient’s age

l Patient’s gender

l Patient’s discharge status

l Prevailing wage rate in the area

l Extra payments for teaching hospitals

l  xtra payments also for “outliers”: patients costing far
E
beyond usual expenses

iv
...
DRGs generally do not apply to psychiatric, pediatric, or
physical rehabilitation cases
...
Resource-based relative-value scale (RBRVS)
RBRVS is a program used to determine how much money providers should be compensated
...

This program assigns a relative value to procedures and services
performed, and is adjusted by geographic region
...
Sets government payments to physicians (and insurance
companies, as well)

ii
...
Payments are made using a formula that includes:

l Amount of time, work, skill, and effort required

l 
Typical costs of physician’s practice (including malpractice premiums)

l  ypical cost of physician’s postgraduate (residency, felT
lowship) training

l Typical office overhead

iv
...

She is lost beneath the surface for 30 minutes before her parents find her on
the pond bottom and pull her up
...
The girl has a body temperature of 19° C and no pulse
...
A helicopter takes the patient to a
nearby hospital where she is wheeled directly to an operating room
...
She requires placement
on extracorporeal membrane oxygenation
...
She
suffered extensive neurologic deficits; however, by age 5, after extensive
outpatient therapy, she recovers completely and is like any other little girl again
...
At the time of discharge
from the hospital, the child is described as having ‘head to toe jaundice,’ but
a bilirubin test had still not been done, nor had his blood type or Coombs
test been performed
...
A few days later the baby’s mother calls the newborn nursery stating
that her son is still yellow, lethargic, and feeding poorly
...
The mother
continues to notice that the child is not well
...
On day 6 in the afternoon, the child has a high pitched cry,
respiratory distress, and increased tone
...
The child is ultimately diagnosed with
classic textbook kernicterus, resulting in permanent brain damage
...
In one case a series of complex processes result in an
excellent outcome, while in another a patient suffers preventable injury
...

Patients are at risk for sustaining harm from the health care system and do so at
an alarmingly high rate
...
The cause of these adverse events is not usually intentional injury (i
...

someone intending to harm patients), but rather is due to the complexity of the
health care system combined with the inherent capability of human error
...
Media reports of catastrophic injury resulting in disability or death due
to medical care often reach news headlines, and are a significant concern to patients, families, and members of the health care team
...

Ensuring patient safety is the responsibility of every member of the health care
team
...
Patients, providers, payers, and employers are all stakeholders in
improving patient safety
...
Systems in health care
delivery can be redesigned to create safeguards and safety nets which make it difficult for members of the health care team to make errors that harm patients
...


218

Chapter 17

l

Basic Science of Patient Safety

SCOPE OF THE PROBLEM
In 1999 the Institute of Medicine (IOM) published its landmark publication,
‘To Err is Human: Building a Safer Health System,’ reporting that at least 44,000
people—and perhaps as many as 98,000—die in hospitals each year as a result of
medical errors that could have been prevented
...
Approximately 1 in 10 patients
entering the hospital will suffer harm from an adverse event
...

The impact of these errors can have dramatically negative effects on patients,
their families, and the health care personnel involved
...

Medical errors are the eighth leading cause of wrongful death in the United
States
...

Some of the more common contributors to medical errors and adverse patient
events are as follows:
Medication errors represent one of the most common causes of preventable patient harm
...
5 million deaths occur each year in the United States
due to medication error
...

Common causes of medication error
• Poor handwriting technique on a prescription pad or order form, resulting in a pharmacist or nurse administering the wrong drug or wrong dose
• Dosing or route of administration errors
• Failure to identify that a given patient is allergic to a prescribed medication
• Look-alike or sound-alike drugs (e
...
, rifampin/rifiximin)

Figure 17-1
...

• The 5 Rs help to confirm several key points before the administration of
any medication
...
The computer software (i
...
electronic health record) can automatically check for prescribing errors or allergies
...
The World Health Organization (WHO) estimates that
the mortality from health-care-associated infections ranges from 12–80%
...
UTI accounts for 40%
of all HAI; >80% of these infections are attributable to use of an indwelling
urethral catheter
...

Central line associated bloodstream infection (CLABSI) is another common HAI, and among one of the most common infections observed in patients admitted to critical care units
...
Symptoms include fever, chills, erythema at the skin surrounding
the central line site and, in severe cases, hypotension secondary to sepsis
...
Checklists have
been developed which provide best practices for the placement of central
lines that lower the risk of infection (e
...
, hand washing, gloving and gowning, sterile barriers, and early removal of central lines when possible)
...
These
ventilator-associated pneumonias (VAP), a subtype of HAP, tend to be more
serious because patients are often sicker and less able to mount effective immune responses
...

Common symptoms include coughing, fever, chills, fatigue, malaise, headache, loss of appetite, nausea and vomiting, shortness of breath, and sharp or
stabbing chest pain that gets worse with deep breathing or coughing
...
g
...

Surgical site infections (SSI) occur following a surgical procedure in the
part of the body where the surgery took place
...
g
...
Symptoms include fever, drainage of cloudy fluid from
the surgical incision or erythema and tenderness at the surgical site
...
g
...
e
...
Pre-operative antibiotics have been effective in reducing the rate of SSIs
...
Over 1/3 of elderly people age >65 fall each year
...
S
...
Approximately 30% of inpatient falls result in injury,
with 4–6% resulting in serious injury
...
Injuries from falls also increase hospital costs
...
Some risk factors include advanced age (age >60),
muscle weakness, taking >4 prescription medications (especially sedatives, hypnotics, antidepressants, or benzodiazepines), impaired memory, and difficulty
walking (e
...
use of a cane or walker)
...

Unplanned readmissions occur when patients unexpectantly return to the hospital <30 days after being discharged
...
Several factors can lead to a
hospital readmission, such as poor quality of care or breakdowns in communication during a transition of care (e
...
hospital to rehabilitation center)
...

For example, a 79-year-old patient treated for congestive heart failure (CHF) returns to the hospital 10 days after discharge with exacerbation of CHF
...
Improving communication, patient education and providing appropriate support to patients at risk for readmissions are all strategies to reduce unplanned readmissions
...
There
were numerous steps that were required to get right in the care of the patient
...

Machines break down, a team can’t get moving fast enough, or a simple step is
forgotten or the wrong step applied
...
Couple that with the fact that human
beings are prone to error, especially when working under less-than-ideal circumstances, and it is no wonder that medical errors pose such a threat to health care
...
Understanding medical error and the science of patient safety can help us
design a health care system capable of getting it right every time
...


The potential for human error is amplified by poor working conditions
...
g
...
g
...


221

USMLE Step 1

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Behavioral Science and Social Sciences

The following is a mnemonic to help assess the fitness of a health care professional to attend to patient care
...
10 (legally intoxicated by most
standards) (Dawson & Reid, 1997)
...
Lack of appropriate communication creates situations where
medical errors are likely to occur
...
Errors at the time of transitions or
handoffs are among the most common communication errors in healthcare
...
g
...
Using techniques of structured communication (e
...
, SBAR,
call-backs) can help safeguard against errors
...
A growing recognition of the need for improved teamwork
in health care has led to the application of teamwork training principles,
originally developed in aviation, to a variety of clinical settings
...
Team members are trained to cross-monitor; check each other’s actions, offer assistance when needed, and address errors in a nonjudgmental
fashion (i
...
watch each other’s backs)
...
Remember, a chain is only as strong as its weakest link
...
; Brennan, Troyen A
...
Preventing Medical
Injury
...
19(5): 144–149, 1993

Errors can be categorized as slips, lapses, or mistakes
...
g
...
Slips are observable
...
g
...
Lapses are generally not observable (i
...
one
cannot directly ‘see’ a lapse of memory)
...
’
• Mistakes are a specific type of error brought about by a faulty plan or
incorrect intentions; the intended action is wrong (e
...
extubating a
patient prematurely based on misapplication of guidelines, or treating a
patient for a suspected pneumonia when the patient was misdiagnosed
and actually has a pulmonary embolism)
...
Types of Error

It is important to differentiate errors (slip, lapse, or mistake) from violations
...
g
...
A health care professional may consider that a violation is
well-intentioned; however, it would still technically constitute a ‘violation’
rather than an error
...
If this act led to an adverse medication reaction
due to a missed allergic reaction, it would technically be considered a
violation and not an error
...

• Adverse events are harms or injuries that result directly from medical
care, not from negative outcomes due to the patient’s disease or medical
condition
...

Diagnostic errors account for at least 17% of preventable errors in hospitalized
patients
...

• No-fault errors may happen when there are masked or unusual symptoms of a disease, or when a patient has not fully cooperated in care
...

• Cognitive errors frequently result from a diagnosis that was wrong,
missed, or unintentionally delayed due to clinician error
...

A wrong diagnosis may occur when the clinician holds on to a particular diagnosis (usually the initial one, in a phenomenon called anchoring bias) and becomes
dismissive to signs and symptoms pointing to another diagnosis
...
He has a history of alcoholism
...
However, holding on to this diagnosis to the exclusion of any other
diagnosis—despite the patient’s denial of alcohol use for several years, normal
blood levels of pancreatic enzymes, and abnormal EKG which is ignored—would
be an anchoring error
...
Clinicians should regard conflicting data as evidence for the need to continue to seek the true diagnosis (e
...
in the case above; acute MI) rather than as anomalies to be disregarded
...
e
...

It is estimated that thousands of hospitalized patients die every year due to diagnostic errors
...
Poor teamwork/communication between clinicians and a lack of reliable systems for common outpatient clinical situations
(e
...
, triaging acutely ill patients by telephone and following-up on test results)
have been identified as predisposing factors for diagnostic error
...
Most are highly
trained and competent; however, the nature of health care is extremely complex,
and people, despite good intentions, are still capable of making errors
...
Rather than penalize individuals
who make honest mistakes, the goal of patient safety is to redesign systems to be
more fool-proof and able to compensate for human error
...
However, this approach does not improve safety
...

Only 5% of patient harm is due directly to incompetence or poor intentions
...
Unfortunately, health care has a long tradition of a blame culture
...

The most effective approach to reducing harm from medical error is to find out
how the error happened, rather than who did it, and then fix the system to prevent errors from causing injury to patients
...


225

USMLE Step 1

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Behavioral Science and Social Sciences

SYSTEMS APPROACH TO FAILURE
An understanding of medical error requires an understanding of the systems failures underlying the majority of adverse patient events
...
Errors that harm patients tend to have multiple causes that are ingrained
in this complex system
...

The Swiss cheese model encompasses the understanding that patient harm often
results from multiple, upstream or proximal errors
...
Under normal circumstances one of the barriers works to prevent
patient harm (e
...
the nurse catches that the medication ordered is the wrong dose
before giving it to the patient); however, occasionally the perfect storm scenario arises where the holes line up and allow an error to reach the patient resulting in harm
...
Many more layers exist but the point is
that no single barrier is foolproof
...


Note
Approximately 80% of medical
errors or adverse patient events
are system-derived
...
For instance, in
an emergency situation, all 3 of the surgical identification safety checks mentioned above may fail or be bypassed, resulting in the surgeon meeting the patient
for the first time in the operating room already under anesthesia
...
g
...

Under the blame culture traditionally present in health care, a person may be
reprimanded for an error but the holes in the system are not addressed; making it
quite probable that the same error will be committed by someone else in the future leading to more patient harm
...

Some holes due
to active failures
Hazards

Other holes due to
latent conditions
Losses

Source: James Reason

Figure 17-3
...
These industries have also made changes to improve communication, teamwork, and the culture of safety
...
Most motor vehicle collision (MVC) deaths are due to driver error or deliberate misbehavior (e
...
speeding, running a red light, failure to wear a
seatbelt, etc
...
Drivers today are not necessarily safer drivers than before; however, design changes in cars (e
...
collapsible steering columns, airbags) and safe
highway design (e
...
improved lighting, deformable lampposts) have resulted in
drastic reductions in mortality from MVCs
...
Health care must create safety nets that absorb mistakes before they
reach patients
...
g
...
Healthcare professionals have traditionally
shied away from discussing errors with patients, due to fear of precipitating a
malpractice lawsuit, issues of professional embarrassment or discomfort with the
disclosure process
...

The first priority after an event which causes patient harm is to care for the patient’s medical needs
...

Following an adverse event, patients and families want to hear an apology and to
know what is being done to prevent the error from harming someone else in the
future
...
Honesty and transparency are essential
...
g
...
Such practices are unethical and betray the professional responsibility we
have to patients
...

Often the most senior physician responsible for the patient and most familiar
with the case will make the official disclosure
...
Reporting errors is essential for error prevention and provides opportunities to improve
processes of care by learning from failures of the health care system
...
Individuals who report incidents must not be
punished or suffer other ill-effects from reporting
...

The identities of reporters should not normally be disclosed to third parties
...
To overcome
these barriers, reported events should be reviewed and acted upon in a timely
fashion, and the system for reporting errors should be made as straightforward
as possible
...
For example, an interventional cardiologist accidentally orders the wrong dose of medication during a cardiac catheterization; however, the
nurse who has worked with this cardiologist for years knows the correct dose
intended and makes the appropriate adjustment
...

Health care professionals need to be educated about medical error identification,
including the identification and importance of near-misses
...
One person’s near-miss may be the next person’s
fatal error
...


Note
Estimates are that voluntarily reported
medical errors only reflect 10–20% of
actual errors
...
Every error represents an opportunity to improve a process; however, in order to improve, these errors must be recognized
and made known so that system-wide learning and performance can take place
...
RCA is retrospective in nature; the focus is on
systems and process rather than individual blame
...
RCA
is not applicable to negligence or willful harm
...
This type of diagram is used to explore
and display all the possible causes of a particular error
...
Sample Fishbone (Ishikawa) Diagram

The RCA allows the team to identify problems in the system or process of care
...
Recommendations commonly
consist of one or more of the following actions: standardizing equipment, using
double checks or backup systems, employing forcing functions that physically
prevent users from making common mistakes, making changes to the physical
set-up, updating or improving technology, using cognitive aids (e
...
checklists or
mnemonic devices), simplifying a process, educating staff or implementing new
safety policies
...
The goal of FMEA is to prevent patient problems before they occur
...


PRINCIPLES OF QUALITY IMPROVEMENT
‘Every system is perfectly designed to get the results it gets
...
D
...
Some everyday examples of
safety design outside of health care are seatbelt alarms in cars, heat-sensitive fire
sprinkler systems, and tip-over switches which automatically turn off space heaters that have accidentally fallen over
...
The report recommended a redesign of the American health care system
and provided principles for guiding quality improvement
...
Safe: avoidance of injuries to patients from the care that is intended to
help them
2
...
Effective: provide care based on scientific knowledge likely to benefit
patients
4
...
Equitable: provide care that does not vary in quality because of personal
characteristics such as gender, ethnicity, geographic location, and socioeconomic status
6
...
e
...

• Improve the patient experience of care (including quality and satisfaction)
• Improve the health of populations
• Reduce per capita cost of health care

Measures of Quality
There are 3 traditional categories of measures used in quality improvement:
structure, process, and outcomes
...
g
...

• Process relates to how the system works (e
...
how often nurses use bar
coding to identify patients prior to administering medication)
...
g
...

Outcomes are often difficult to assess in quality improvement, and many
people often use process measures as a surrogate for outcomes
...

A fourth type of measure introduced to quality improvement is the concept of a
balancing measure
...
g
...


Models of Quality Improvement
One example of a common quality improvement model is a combination of
building and applying knowledge to make an improvement by asking 3 questions and using the PDSA (plan, do, study, act) cycle developed by W
...


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1
...
How will we know whether a change is an improvement?
3
...


What are we trying to accomplish?
How we will know that a change is an improvement?
What change can we make that will result in an improvement?

ACT

PLAN

STUDY

DO

Figure 17-5
...
e
...
The term comes from the use in statistics of the Greek Letter
(sigma) to denote Standard Deviation from the mean
...
4 defects (or errors) per million
...

• DMAIC (define – measure – analyze – improve - control): an improvement system for existing processes falling below specification
–– Define: Define the problem in detail
...

–– Analyze: Do in-depth analysis using process measures, flow charts
and defect analysis to determine the conditions under which defects
occur
...

–– Control: What steps will you take to maintain performance?

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Lean (also called Lean Enterprise or Toyota Production System) is an improvement process that seeks to improve value from the patient’s perspective, by reducing waste in time and resources that do not enhance patient outcomes
...
For example, a preoperative EKG obtained on a healthy 21 year-old with no cardiac symptoms undergoing a small outpatient procedure can be considered a wasteful test that does
not help the patient
...
A flowchart is a visual illustration of all the steps or
parts of a process in patient care
...

Flowcharts are more accurate and effective when all representative members of
a health care team actively participate in their design
...
Specifically, they
can help to identify steps that do not add value to the process (e
...
unnecessary
duplication of services), to determine areas of delay in care, and to discover failure points in the system
...
It is based on the classic 80/20 rule from
economics, where 80% of the world’s wealth is described to be in the hands of an
elite 20% of the population
...
In essence, it is a method
of prioritizing problems, highlighting the fact that most problems are affected
by a few factors and indicating which problems to solve and in what order
...
The ordering is an
important step because it helps the team concentrate efforts on those factors that
have the greatest impact
Run charts (or time plots) are graphs of data collected over time which can help
determine whether an intervention or enhancement in the patient care process
has resulted in true improvement over time or rather if it simply represents a
random fluctuation (that might be incorrectly interpreted as a significant improvement)
...
g
...
g
...
The median (or 50th percentile) is measured using
baseline historical data and then compared to outcomes measured following the
quality improvement intervention
...
a random-pattern
...


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Falls per 1,000 occupied bed days, by month
8
7
6
5

Falls

4

Median

3

Goal

2
1
0

Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
Figure 17-6
...
gov)

A Shewhart (or control chart) applies formal statistical calculations (statistical
process control) to determine whether the observed rise and fall of a quality measure over time is within a predictable range of variation or is an indication of
a significant change in the system
...

A convenience sample is the study group or population used in the test of a
quality improvement initiative
...
This is not the same process often used in
randomized controlled trials, and thus may not be an accurate reflection of the
larger group
...


LEADING CHANGE IN PATIENT SAFETY
Patient safety is the professional responsibility of everyone on the patient care
team
...
Changing behavior is difficult, and
there are always multiple barriers to change efforts
...

Successful leadership can be achieved even without a formal position of authority
...
Good leaders are able to organize a team, articulate clear goals, manage conflict resolution, and make decisions based on the input of team members
...


KEY DEFINITIONS
• Adverse event: any injury caused by medical care
–– An adverse event results in unintended harm to a patient by an act
of commission or omission, rather than by the underlying disease or
condition of the patient
...
It simply indicates that an undesirable clinical outcome resulted from some aspect
of diagnosis or therapy, not an underlying disease process
...

• Authority gradient: command hierarchy of power or balance of power,
measured in terms of steepness
–– First used in aviation to describe the phenomenon where pilots and
copilots failed to communicate effectively in stressful situations due
to the significant difference in their perceived expertise or authority
...

Most health care teams require some degree of authority gradient;
otherwise roles are blurred and decisions cannot be made in a timely
fashion
...

• Brief: short planning session prior to the start of a clinical activity, in
order to achieve team orientation, establish expectations, anticipate
problems, and plan for contingencies
• Checklist: algorithmic listing of actions to be performed in a given clinical setting, with the goal to ensure that no critical step will be forgotten
–– Though a seemingly simple intervention, checklists have played a
leading role in the most significant successes of the patient safety
movement, including the near-elimination of central line–associated
bloodstream infections in many intensive care units
...
g
...

• Closed-loop communication: a type of communication whereby, when
a request is made of team members, someone specifically affirms out
loud that he or she will complete the task and states out loud when the
task has been completed
–– For example, during a cardiac resuscitation a physician orders a
medication to be given intravenously and the nurse verbally confirms
receipt of the order and verbally confirms when the medication has
been administered as requested
...
e
...
e
...
Failing to prescribe a proven medication with major benefits for an eligible patient
(e
...
low-dose unfractionated heparin for venous thromboembolism
prophylaxis for a patient after hip replacement surgery) is an error
of omission
...

Errors can also be defined in terms of active or latent as coined by
Professor James Reason, one of the founders in the field of safety
science
...
g
...
They are generally readily apparent (e
...
, pushing an incorrect button, ignoring a warning light) and
almost always involve someone at the frontline
...
In other words, errors at the sharp end are
noticed first because they are committed by the person closest to the
patient
...
g
...
g
...

Latent errors (or latent conditions), in contrast, refer to less apparent
failures of organization or design that contribute to the occurrence
of errors or allow them to cause harm to patients
...
For example, policies
that allow a patient to enter an operating room and start an operation before confirming the patient’s identify, intended procedure and
site of surgery are considered latent errors that can result in wrong
patient or wrong site surgery
...
One
of the first forcing functions identified in health care was the removal
of concentrated potassium from general hospital wards
...


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• Handoffs: the process whereby one health care professional updates another
on the status of ≥1 patients for the purpose of taking over their care
–– An example includes a resident physician who has been on call overnight telling an incoming resident about the patients admitted who
require ongoing management
...
Handoffs
are a potential source of patient safety failure from the lack of important information being conveyed or misinformation being conveyed
...
g
...
g
...

• Medication reconciliation: process of avoiding unintended inconsistencies in medication regimens which can occur with any transition in care
(e
...
hospital admission, transfer to ICU, discharge to rehab center) by
reviewing the patient’s current medication regimen and comparing it
with the regimen being considered for the new setting of care
–– Medical reconciliation helps to ensure that the intended medications
are continued, and that medications that are supposed to be discontinued are not inadvertently continued
...
g
...

• Near-miss (or close call): error or other incident which does not produce
patient injury, but only because of intervening factors or pure chance
–– This good fortune might reflect robustness of the patient (e
...
, a
patient with penicillin allergy receives penicillin, but has no reaction)
or a fortuitous, timely intervention (e
...
, a nurse happens to realize
that a physician wrote an order in the wrong chart)
...
Patient safety is also an attribute of
health care systems; it minimizes the incidence and impact of, and
maximizes recovery from, adverse events
...
For example, a laboratory technician calling a
physician with a critical lab value may request that the physician read
back the critical lab value to ensure it was received correctly
...
A central tenet of RCA
is to identify underlying problems that increase the likelihood of
errors, while avoiding the trap of focusing on mistakes by individuals
...

• SBAR: a form of structured communication first developed for use in
naval military procedures; it stands for situation (what is going on with
the patient?), background (what is the clinical background or context?),
assessment (what do I think the problem is?), recommendation/request
(what would I do to correct it?)
–– It has been adapted for health care as a helpful technique for communicating critical information that requires immediate attention and
action concerning a patient’s condition
...

• Sentinel event: adverse event in which death or serious harm to a patient
has occurred; used to refer primarily to events that were not at all expected
or acceptable (e
...
, an operation on the wrong patient or body part)

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• Violation: intentional or deliberate deviation from safe operating procedures, standards, or policies
–– A violation is different from an error, which is an unintentional
action
...

• Wrong-site procedure: operation or procedure done on the wrong part
of the body or on the wrong person; it can also mean the wrong surgery
or procedure was performed
–– Wrong-site procedures are rare and preventable, though they do still
occur
...


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Review Questions
1
26
...
The treating clinician forgets to ask about allergies and the
patient is unaware that his severe allergy to penicillin is not known to the
treatment team
...
Which of the following is the most accurate description of
the medical error?
(A) Slip resulting in a near miss
(B) Violation resulting in a near miss
(C) Lapse resulting in an adverse event
(D) Violation resulting in patient injury
(E) Non-preventable adverse event
1
27
...
The intern prescribes a six month course of warfarin without reviewing the patient’s other medications
...

The pharmacy computer system is broken and the drug is filled manually, which does not enable the computer system to alert to the drug –drug
interaction
...
The patient fills the prescription at a local drug store and suffers
a significant bleeding complication requiring re-hospitalization and surgery
...
As a member of the clinical team you are interested in developing a new
system to more closely monitor blood glucose levels of diabetic patients
admitted to the hospital for vascular wound care
...
Which of the following statements is correct regarding the
PDSA cycle?
(A) The PDSA cycle begins with full scale implementation
(B) The PDSA cycle consists of small, rapid test of new initiatives
(C) Changes from PDSA are based on expert intuition, and do not require
data collection or interpretation
(D) PDSA is a means of analyzing past errors in order to design system
based interventions
(E) The PDSA cycle requires a randomized control trial
1
29
...
The patient has been stabilized medically; however, is under
24-hour monitoring by the nursing staff due to repeated attempts at selfharm
...
The mistake is noticed 15 minutes into
the new shift, and a member of the nursing team is assigned to watch the
patient
...
Which of the following statements about this
event is correct?
(A) This is a sentinel event and should be reported to the medical board
(B) This is a sentinel event and should be reported to the hospital and family
(C) This is a near miss and should be reported to the hospital
(D) This is a near miss and should be reported to the patient and family
(E) This is a near miss and no reporting is required since the patient was
not harmed
1
30
...

The mother typically sees the physician and receives antibiotics to treat
her child’s condition
...
The
prescription is filled at a new pharmacy that does not have the patient’s
prior medical records on file
...
Which of the
following statements is correct regarding root cause analysis (RCA)?
(A) RCA involves a retrospective, systems approach to error analysis
(B) RCA is a prospective approach to systems redesign
(C) RCA involves only the individual(s) directly involved in the error
(D) RCA is only performed for errors resulting in patient death
(E) Due to privacy laws the results of RCA are confidential and not shared

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1
31
...
The team develops a new clinical protocol
to help reduce hospital acquired pneumonia in ventilated patients
...
The changes includes head of bed elevation, daily oral care, daily assessment of readiness to extubate and having
access to infectious disease specialists for consultation in the treatment of
ventilator-associated pneumonia
...

(C) Monitor the number of patients who self-extubate prematurely during
the daily assessment of readiness to extubate over a 3 months period
following implementation of the new protocol
(D) Monitor the number of infections over 3 months following implementation of the new protocol
(E) Determine the wait time for starting antibiotics in patients with suspected ventilator-associated pneumonia
...
A geriatric team is interested in decreasing the number of patient falls in
their nursing home
...

Following this intervention, the rate of patient falls per month is followed
for 12 months on a run chart
...
Which of the
following best describes the results of the run chart?
Patient Falls

Intervention
20
15
10

Falls

5
0

0

2

4

6

8

10

12

14

(A) The intervention led to a significant decrease in patient falls
(B) The intervention led to a significant increase in patient falls
(C) The intervention resulted in no change in patient falls
(D) The impact of the intervention is subjective
(E) The impact of the intervention is inconclusive

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1
33
...
Postoperatively
during her hospital stay she was started on deep vein thrombosis (DVT)
prophylaxis medication with plans to continue the medication upon discharge
...

The patient is not continued on her anticoagulation medication and sustains a DVT leading to a fatal pulmonary embolus 3 weeks after transfer
...
Answer: C
...
The result of the described
error was harm to the patient in the form of anaphylaxis with the need for
resuscitation, and therefore is categorized as an adverse event
...
A violation is a deliberate act of not
following policy or procedures, which was not the situation in this scenario
...
The adverse event
described is the result of an error and is completely preventable
...
Answer: D
...
In the Swiss-cheese
model, safety barriers are recognized as having unintended weaknesses (i
...

holes) which can occasionally align and allow an error to result in patient
harm
...
Attempting to penalize individuals who make honest errors
or eliminate the potential for human error yields limited results
...
Answer: B
...
These interventions are small scale, rapid tests of
new initiatives
...
They do not require the rigor of randomized
controlled trials
...


Act

Plan

Study

Do

129
...
The event described is a near miss; there was an error which
fortunately did not result in patient harm
...
A sentinel event is an adverse event resulting in
serious or permanent injury to a patient
...
Answer: A
...
It is typically performed for errors resulting in significant patient
harm, but can be performed for any adverse event that a team wishes to
review
...
Although the details such as the
names of the individuals involved in the event are not shared publically, the
general findings of the RCA can be shared throughout the system in order
to improve the quality of the system
...
Answer: D
...
Compliance rates
in following guidelines are a process measure
...
The number of patients
prematurely self-extubating would be a balancing measure
...


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132
...
A run chart provides a dynamic display of a process over time
...

Run charts also provide the foundation for the more sophisticated method
of statistical analysis using control charts
...
However, without a baseline for comparison, one cannot determine from this run chart
whether or not any significant change has occurred
...
 nswer: B
...
It is a form of ‘policing’ to
ensure that quality standards have been followed
...
It
often involved determining who was at fault after something went wrong
...
The goal of
quality improvement (QI), on the other hand, is to achieve improvement
by measuring the current status of care and then developing systems-based
approaches to making things better
...

Rather, QI seeks to create systems to prevent errors from happening
...
The other interventions are
QA-based and/or simply not as effective in creating and sustaining a positive change
...
See Child abuse
of domestic partner, 115–116
of elderly, 116
substance
...
See also Grief
Advance directives, 199
Adverse events
contributing factors, 218–220
medical errors causing, 225
Age/Aging
disease rates correlated with, 8
facts about, 112–113
leading cause of death by, 52
sexuality and, 70
sleep-wake cycle and, 128
Agnosia, 174
Agraphia, 174
Al-Anon, 57
Alcohol consumption
effects of, 56–58
medical complications of, 57–58
sleep and, 128
Alcoholics Anonymous, 57
Alcoholism, 56–58
Alexia, 174
α (type I) error, 27

Alzheimer disease
...
See Grief
Best interest standard, 200
Baby Boy Doe case, 198
in Eichner vs
...
See Probability
Bipolar disorder, 152
Birth defects, 53
Blame culture approach, to medical error, 225
Blocking, as defense mechanism, 88, 95
Body dysmorphic disorder, 156
Borderline personality disorder, 160–161, 163
Brain
abnormalities in schizophrenia, 149
and behavior, 176, 176–179
Brain lesions, 176–177
and memory, 178
Breathing-related sleep disorder, 130
Broca aphasia, 174
Bruxism, 132
Bulimia nervosa, 153, 154
Bupropion, 189
Buspirone, 192

246

C

Caffeine, effects and treatment for absue of, 59
CAGE questions, 57
Cancer rates, 51
incidence and death, 51
Cannabis, effects and treatment for abuse of, 59
Capitation payments, 49, 214
Cardiovascular effects
of antipyschotics, 185
of cyclic antidepressants, 186
Case-control study, 14
differentiating from other observational studies, 17
odds ratios in, 16
colorectal cancer and family history, 16
lung cancer and smoking, 16
Case-fatality mortality rate, 8
Case report observational study, 14
Case series report observational study, 14
Cataplexy, 129
Catatonic symptoms, in schizophrenia, 147
Categorical scale, 29
Cause and Effect diagram, in root cause analysis, 228, 228–229
Cause-specific mortality rate, 8
Central line associated bloodstream infection (CLABSI), 220–221
Central nervous system (CNS) effects
of antipsychotics, 185
of commonly abused substances, 60
of cyclic antidepressants, 186
Central tendency, 21, 21–22
skewed, 22
Cerebellum, 179
Child abuse, 113–114, 116
sexual, 115
Child development
intellectual disability, 145
milestones in, 105, 105–107, 108–109
principles of, applying, 110–113
Children
...
See Child development
discipline of, 110
DSM 5 diagnoses in, 145–146
legal and ethical issues related to, 201
mentally ill, detention of, 203
Chi-square, 29, 31
for nominal data, 31
Chlamydia, 66
Circumcision, female, 114
Clang associations, 146
Classical conditioning, 75, 75–76
behavior therapy/modification based on, 79, 81
Clinical Trials
...
S
...
S
...
, 169, 170
Delta sleep, 124
sleep deprivation and, 126
Delusions, 146
Dementias
...
Edward, 230
Denial, as defense mechanism, 88, 95
Dependent personality disorder, 163
Depersonalization disorder, 159
Depression
behavioral models of, 81–82
bipolar disorder, 152
grief vs
...
See Child development
in infant, 105–107, 106, 108–109
pubic hair, 109
Diagnostic and Statistical Manual (DSM 5)
...
Dillon, 198
Ejaculation, in sexual response cycle, 67
premature, 69
Elderly
abuse of, 116
and aging, facts about, 112–113
sleep-wake cycle in, 128
suicide among, 113
Electroconvulsive therapy (ECT), 188–189
Electroencephalography (EEG), of sleep stages, 126
Emergency detention, 203
Enkephalins, 181
Enuresis, 132
Epidemiology, 3–8
mood disorders, 152
neurocognitive disorders, 170
substance-related disorders, 61
suicide, 45–46, 46
Erectile disorder, in males, 68
Error
in hypothesis testing, 27
in medical care
...
See Legal and ethical issues
Euthanasia, 200
active, 200
Excessive daytime sleepiness (EDS), 129
Exhibitionism, 67
Experimenter expectancy, 12
effects associated with, 13
Exposure therapy, 79, 81
Extinction
in classical conditioning, 75
in operant conditioning, 76
Extinction therapy, 80, 81
Extrapyramidal (EP) reactions, to antipsychotics, 184

248

F

Facilitation, in physician-patient communication, 136
Factitious disorder, differentiating between somatic symptom
disorder and, 158
Fading therapy, 81
Failure mode effects analysis (FMEA), 229
Failure, systems approach to, 226, 226–228
Falls, in health care settings, 221
Family life, 43–44
FDA approval, for intervention study, 17
Feeding tubes, 200
Fee-for-service payments, 212
PPOs and, 214
Females
elderly, suicide rates among, 113
orgasm disorder in, 69
sexual interest arousal disorder in, 68
sexuality and aging in, 70
Fetal alcohol syndrome (FAS), 56
Fetishism, 68
Figures, copying ability by age, 106, 107
Fishbone diagram, in root cause analysis, 228, 228–229
5 Rs strategy, in medication administration, 219
Flight of ideas, 146
Flowcharts, for quality improvement, 232
Fluphenazine, 185
Frontal cortex, 176
Frontal/temporal disease, 172
Frotteurism, 68
Fugue state, 159
Functional neurological symptom disorders, 157

G

Gamma amino-butyric acid (GABA), 182
Gender dysphoria, 68
Gender identity, 68
Generalized anxiety disorder (GAD), 154
Genetics, contribution to alcoholism, 56
Genitopelvic pain disorder, 69
Global aphasia, 175
Glue sniffing, effects and treatment for, 59
Glutamate, role in schizophrenia, 148
Glutamic acid, 181
Gonorrhea, 66
Good Samaritan Laws, 202
Grief
Kubler-Ross stages of, 111

H

Hallucinations
defined, 146
hypnagogic and hypnopompic, 129
Hallucinogens, effects and treatment for abuse of, 59
Haloperidol, 185
Halstead-Reitan Battery, 102
Harm to patient
...
See Cannabis
Hawthorne effect, 12, 14
Health belief model, 138

Index
Health care delivery systems
complexity of, 221
outcomes in, case studies, 218–219
payment methods in, 49
utilization trends, 48–49
Health care professionals
fitness for patient care, 203, 222
medical error identification by, 228
practice questions concerning, 204–205
rules of conduct for, 199–203
substance-related disorders among, 61
Health maintenance organization (HMO), 213
types of, 214
Health power of attorney, 200
Helplessness, learned, 81
Hemineglect/hemi-inattention, 175
Hemispheric dominance, 174
Heroin, effects and treatment for absue of, 59
Herpes simplex virus, type 2 (HSV-2), 66
High-level flowcharts, for quality improvement, 232
Hippocampus, 178
Histrionic personality disorder, 160, 162
HIV/AIDS, 49–50
neurocognitive disorder associated with, 173–174
Hoarding disorder, 156
Holmes and Rahe scale, 99
Homicide, child victims of, 115
Homicide rate, by age, 47
Homosexuality, 69–70
Hospital-acquired infections (HAI), 220–221
Hospital-acquired pneumonia (HAP), 220
Hospitalization trends, 49
for mentally ill, 47
Human papilloma virus (HPV), 66
Humor, as defense mechanism, 93, 95
Huntington chorea, 172–173
Hydrocephalus, normal pressure, 173
Hypertensive crisis, MAOI use and, 187–188
Hypothalamus, 178
Hypothesis testing, 26–27
Hypoxyphilia, 68

I

Identity formation, in teenagers, 110
Illness anxiety disorder, 157
Illness, child’s concept of, 112
Illusions, 146
Immature defenses, 88–89, 93
Impotence, 68
Imprinting, 108
IM SAFE mnemonic, 222
Incidence
calculating, lung cancer example, 7
factors affecting, 6
Incidence rate, 3
calculation for, 3
considerations in, 3–4
Indemnity insurance, 212
Independence, probability and, 19
Infants
developmental milestones in, 105, 105–107, 108–109
mortality rate, in U
...
, 47, 52
sleep-wake cycle in, 128

Infections, hospital-acquired, 220–221
Inferential statistics, 25–29
Information processing deficits, in schizophrenia, 149
Informed consent, 201
Inhalants, effects and treatment for absue of, 59
Insomnia, 131
Institute for Health Care Improvements (IHI) “Triple Aim”
initiative, 230
Institute of Medicine (IOM)
“Crossing the Quality Chasm,” 230
medication error estimate by, 219
“To Err is Human: Building a Safer Health System”
(IOM report), 219
Instrumental conditioning
...
See Hallucinogens
Klüver-Bucy syndrome, 178
Knowledge-based mistake, medical error and, 223
Korsakoff syndrome, 179
Kubler-Ross stages of grief, 111

L

Lapse in memory, medical error and, 223
Late-look bias, 13
effects associated with, 13
Leading questions, in physician-patient communication, 136
Lead-time bias, 12
effects associated with, 13
Lean (Lean Enterprise/Toyota Production System) model, for
quality improvement, 231
Learned helplessness, 81
Learning
and anxiety relationship, 82
behaviorist model of, 75–78
Learning-based therapies
...
S
...
See also Grief
Low birth weight, 53
Loxapine, 184
LSD
...
See Cannabis
Marital status, well-being index scores for, 44
Marriage, 43
age at, divorce rate and, 44
Masochism, 67
Masturbation, 69
Matched pairs t-test, 29, 31
Mature defenses, 93, 93–94
MDMA (Ecstasy), 60
Mean, 21
standard deviation and, 23, 24
Measurement bias, 12
effects associated with, 13
Median, 21
Medical error(s)
actual vs
...
See Quality improvement
systems approach to, 225–227
types of, 223–225
Medicare, 49
hospital readmission rates, 221
Medication errors
causes of, 219
IOM estimate of, 219
reduction strategies, 219
Melatonin, sleep deprivation and, 127
Memory, brain lesions and, 178
Memory lapse, medical error and, 223
Mental illness
detention of children with, 203
health care delivery and, 48
patient rights and, 202–203
Mescaline
...
medical errors, 228
Necrophilia, 68
Negative predictive value, 10
Negative reinforcer, in operant conditioning, 76
Neologisms, 146
Neurocognitive disorders, 170–174
Alzheimer type vs
...
, 169, 170–171
HIV-related, 173–174
Neurofeedback therapy, 80
Neuroleptics
...
See also individually named
neurotransmitters
in bipolar disorder, 152
in major depressive disorder, 151
in schizophrenia, 148
sleep-associated, 129
New England Journal of Medicine, readmission to hospital study, 221
“New events,” 3
Nicotine, effects and treatment for abuse of, 59
Nightmares, 131
Night terrors, 131
N-methyl-D-aspartate (NMDA), role in schizophrenia, 148
No-fault errors, in diagnosis, 224

Index
Nominal data, Chi-square analysis for, 31
Nominal scale, 29
Non-neurological effects, of antipyschotics, 185–186
Norepinephrine (NE), 180
sleep and, 128
Normal pressure hydrocephalus, 173
NREM (non-rapid eye movement) sleep, 123, 124
changes over life cycle, 126
Nucleus accumbens, drugs working in, 55
Null hypothesis, 26
error types and, 27
types of, 26
Number Needed to Harm (NNH), 15
Number Needed to Treat (NNT), 15

O

Objective personality tests, 101–102
Objects, phobias associated with, 155
Observational learning, 79
Observational studies
analyzing, 15–16
differentiating, 17
types of, 14–15
Obsessive-compulsive disorder, 156
Obsessive-compulsive personality disorder, 160–161, 162
Occipital cortex, 177
Occupational therapy (OT) programs, for elderly, 113
Odds ratio (OR)
confidence intervals for, 26
in case-control studies, 16
colorectal cancer and family history, 16
lung cancer and smoking, 16
Olanzapine, 186
One-tailed null hypothesis, 26
One-way ANOVA, 29, 31
Open-ended questions, in physician-patient communication, 135
Operant conditioning, 76, 76–78
behavior therapy/modification based on, 79–80, 81
Opiate, effects and treatment for abuse of, 59
Ordinal scale, 29
Organic disorders
aphasias, 174–175
delirium vs
...
See Physician-patient relationships
risks toward, 204, 218
treatment adherence by, 137–138
Patient falls, in health care settings, 221
Patient harm
...
See also Quality
improvement
medical errors compromising
...
See Classical conditioning
PDSA (plan, do, study, act) model, for quality improvement, 230,
230–231
Pearson correlation, 29, 30
Pedophilia, 67
Penetration disorder, 69
Period prevalence, 5
Perseveration, 146, 175
Persistent depressive disorder, 150
Personality disorders, cluster characteristics, 159–162
anxious and fearful, 161, 161–162
dramatic and emotional, 160–161, 162
odd or eccentric, 159–160, 162
Personality tests, 101–102
Pervasive developmental disorders
...
See Health care professionals
Pneumonia, hospital-acquired, 220
Point prevalence, 5
Pons, 179
Positive predictive value, 10
Positive reinforcer, in operant conditioning, 76
Post-test probabilities, 10–11
Poverty of speech, 146

251

USMLE Step 1

l

Behavioral Science and Social Sciences

Power of attorney, for health decisions, 200
Power, statistical, 28
Predictive values, screening tests, 10
Prefrontal cortical (PFC) impairment, 149
Pregnancy, teenage, 65–66
Premature ejaculation, 69
Pressured speech, 146
Pre-test probabilities, 9–10
Prevalence
and incidence, relationship between, 5
calculating, lung cancer example, 7
factors affecting, 6
of medical errors, 218
point vs
...
incidence, 5
“Prevalence pot”, 5
Prevalence rate, 4–5
calculating, 3
prevalence vs
...
, 171–172, 172
warning signs of, 170
Prion disease, 172
Probability(ies)
post-test, 10–11
pre-test, 9–10
rules governing, 19–20
Process, in quality measurement, 230
Professional personnel
...
See Physician-patient relationships
Projection, as defense mechanism, 88–89, 95
Projective drawings, 102
Projective personality tests, 102
Proportionate mortality rate (PMR), 8
Pubic hair development, 109
Punishment, in operant conditioning, 77
p-value
in hypothesis testing, 26–27, 27
meaning of, 28
Pygmalion effect, 12, 14

Q

Quality improvement
measures used in, 230
models of, 230–233
principles of, 229–230
strategies for influencing, 233–234
Quality, measures of, 230
Question types, in physician-patient communication, 136
Quetiapine, 186
Quinlan, Karen Ann, 197

R

Random error, 14
Randomized controlled clinical trial (RCT), 17
Range, 22
Rapport, in physician-patient relationships, 137
Rates, disease
...
See Classical conditioning
Responses, to stimuli in classical conditioning, 76, 76–77
Reticular activating system (RAS), 178
Risk factors, for suicide, 46
Risk(s)
of suicide, 46
relative
...
Wade, 199
Root cause analysis (RCA), of medical error, 228, 228–229
Rorschach Inkblot Test, 102
Rule-based mistake, medical error and, 223
Run charts, for quality improvement, 232

S

Sadism, 67
Safeguards, in systems approach to failure, 225, 225–226
Safety, of patient
...
See Barbiturates; Benzodiazepines
Selection bias, 12
effects associated with, 13
Selective serotonin re-uptake inhibitors (SSRI), 187–188
Sensitivity, in screening tests, 9
ROC curves, 10
Sentence Completion Test, 102
Separation anxiety, 107
Separation anxiety disorder, 107
Separation from partner, data on, 44
Serotonin (5-HT), 181
in mesolimbic pathway, 55
role in schizophrenia, 148
sleep and, 128
Serotonin syndrome, SSRI use and, 188–189
Sexual abuse, of child, 115
Sexual arousal disorders, 68
Sexual desire disorder, male hypoactive, 68
Sexual dysfunctions, 68–69
Sexual effects
of antipyschotics, 185
of cyclic antidepressants, 186
Sexuality, and aging, 70
Sexually transmitted diseases, 66
Sexual pain disorders, 69
Sexual response cycle
in female, 68
in male, 67
Shaping therapy, 80–81, 81
Shewhart control charts, for quality improvement, 233
Sick role components, 137
Six Sigma model, for quality improvement, 231
Skewed curves, 22
Skinner experiment
...
See also individually named
substances
Substance-related disorders
...
S
...
See Adolescents
Teeth-grinding, 132
Temporal cortex, 176
frontal/temporal disease, 172
Tests
screening

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