Preface

The function and state of the mind are of significant importance to the physical

health of an individual. The United States Medical Licensing Examination (USMLE)

is closely attuned to the substantial power of the mind-body relationship and tests this

area extensively on all three Steps of the examination. This review has been prepared

as a learning tool to help students rapidly recall information that they have learned in

the first two years of medical school in behavioral science, psychiatry, epidemiology and

related courses.

The third edition of

BRS Behavioral Sciencecontains 9 sections divided into 26 chap-

ters. All chapters start with a "Typical Board Question" (TBQ), which serves as an ex-

ample for the way that the subject matter of that chapter is tested on the USMLE. Each

chapter has been extensively updated to include the most current information. A total

of at least 500 questions and answers with detailed explanations are presented after

each chapter and in the Comprehensive Examination at the end of the book. Almost all

of these questions have been written expressly for this third edition and reflect the new

USMLE format utilizing clinical vignettes. Seventy-six tables are included in the book

to provide essential information quickly.

Acknowledg

ments

The author wishes to thank Emilie Linkins, Julie Scardiglia, and Elizabeth Niegin-

ski of Lippincott

Williams

and Wilkins for their encouragement, hard work, and prac-

tical assistance with the manuscript. The author also thanks Dr. Steven J. Schleifer,

Chairman, and Dr. Steven S. Simring, Vice-Chairman for Education, both of the De-

partment of Psychiatry of the New Jersey Medical School, for their enthusiasm, help,

and support for this effort. Special thanks to Dr. Marian Passannante of the Depart-

ment of Preventive Medicine and Community Health and Dr. Allan Siegel of the De-

partment of

Neurosciences

for their generous contributions of time and knowledge and

Todd Flannery for his help with the manuscript. Finally and as always, the author

thanks with great affection and respect the caring, involved medical students with

whom she has had the high honor of working over the years.

The Beginning of Life:

Pregnancy through Preschool

Typical Board Question

A mother brings her 8-month-old child in to see the physician for a well-baby checkup. The

mother appears concerned. She tells the doctor that the child recently saw an aunt whom

he had not seen in 6 months. When the aunt approached him, the child cried, seemed fear-

ful, and clung tightly to his mother_ The doctor correctly tells the mother that this fearful,

clinging behavior

(A) indicates that the child is developmentally

delayed

(B) indicates that the child is emotionally disturbed

that

the child

has

been

abused

by his aunt

(D) is more likely to occur in infants exposed to many

different

caregivers

(E) occurs in

normal infants

of this age

when

they are confronted with

an unfamiliar per-

son

(See

"Answers

and

Explanations"

end of

Chapter)

Pregnancy

A. Emotions

Mood changes are common during pregnancy and may be caused by bi-

ological factors (e.g., hormonal fluctuations) as well as psychological

factors (e.g., concern over loss of physical attractiveness).

Pseudocyesis (false pregnancy), the occurrence of many symptoms of

pregnancy although conception has not taken place, may occur in women

who have a strong wish to be pregnant or a strong fear of preg-

nancy.

Many pregnant women form a close emotional relationship with their un-

born infant, thus beginning the bonding process prior to birth (See III A).

B. The marital relationship

Many obstetricians suggest cessation of sexual intercourse about 4 weeks

prior to the expected date of delivery.

Reduction in sexual activity for any reason can put a strain on the mar-

Behavioral Science

erall

Childbirth

Ethnic Group

riage. Extramarital affairs conducted by the husband, if they occur, are

more likely to occur during the last 3 months of the wife's pregnancy.

Birth rate, infant mortality, and cesarean birth

About 4 million children are born each year in the United States.

2. Infant mortality

a. In part because the United States does not have socialized medi-

cine (health care for all citizens paid for by the government through

taxes), the infant mortality rate in the United States is high com-

pared with rates in other developed countries (see also Chapter 23).

Low socioeconomic status, which is related in part to ethnicity,

is associated with high infant mortality (Table 1-1).

Cesarean birth

The number of cesarean births increased from the 1960s to the

1990s, partly because of physicians' fears of malpractice suits if an in-

fant died or was injured during vaginal childbirth.

Recently, however, the number of cesarean births (currently 21% of all

births) has leveled off or even declined, partly in response to increas-

ing evidence that women often undergo unnecessary surgical proce-

dures.

Premature birth

Premature births are defined as those following a gestation of less than

34 weeks or in which the birth weight is under 2500 g.

Premature births, which are associated with low income, maternal ill-

ness or malnutrition, and young maternal age, occur in 6% of births to

white women and 13% of births to African-American women.

Premature birth puts the child at greater risk for emotional, behavioral

and learning problems, physical disability, and mental retardation.

C. Postpartum reactions

Baby blues

Many women experience an emotional reaction called "baby blues"

or "postpartum blues" lasting up to 1 week after childbirth.

Table

1-1.

Ethnicity and Infant Mortality in the United States (1996)

White, Asian American, and Mexican, Cuban,

and other Hispanic American

Puerto Rican American

Native

American (American Indian)

African-American

Infant Deaths per 1000 Live Births

8.6

8.8

14.2

7.2

Chapter 1



The Beginning of Life: Pregnancy through Preschool

b. This reaction results from psychological factors (e.g., the emotional

stress of childbirth, the feelings of added responsibility), as well as

physiological factors (e.g., changes in hormone levels, fatigue).

Treatment involves support and practical help with the infant.

Major depression and brief psychotic disorder with postpartum

onset (postpartum psychosis) are reactions which are more serious than

postpartum blues and which are treated with antidepressant and an-

tipsychotic medications (Table 1-2) (and see Chapters 11 and 12).

III. Infancy: Birth to 15 Months

A. Bonding of the parent to the infant

Bonding between the caregiver and the infant is enhanced by physical

contact between the two.

Bonding may be adversely affected if:

The child is of low birth weight or ill, leading to separation from

the mother after delivery

b. There are problems in the mother-father relationship

Women who take classes preparing them for childbirth have shorter

labors, fewer medical complications, less need for medication, and have

closer initial interactions with their infants.

B. Attachment of the infant to the parent

The principal psychological task of infancy is the formation of an inti-

mate attachment to the primary caregiver, usually the mother.

Table 1-2. Postpartum Maternal Reactions

Maternal

Reaction

Incidence

Onset of

Symptoms

Duration of

Symptoms

Characteristics

Postpartum blues

33%-50%

Within a

Up to 1 week

Exaggerated

("baby blues")

few days

after delivery

emotionality

after delivery and

tearfulness

Interacting well

with friends

and family

Good grooming

Major depressive

5%-10%

Within 4 Up to 1 year

Feelings of

episode

weeks after

without

hopelessness

delivery

treatment;

and help-

3-6 weeks

lessness

with treatment

Lack of pleasure

or interest in

usual activities

Poor grooming

Brief psychotic

0.1%-0.2%

Within 2-3

Up to 1 month

Hallucinations,

disorder,

weeks after

delusions, or

postpartum

delivery

other psychotic

onset ("postpartum

symptoms

psychosis")

Mother may

harm infant

Behavioral Science

Separation from the primary caregiver between 6-12 months of age

leads to initial loud protests from the infant.

With continued absence of the mother, the infant is at risk for anaclitic de-

pression, in which he is withdrawn and unresponsive toward others.

An infant may suffer from anaclitic depression even when he is living

with his mother if the mother is physically and emotionally dis-

tant and insensitive to his needs.

Depressed infants may exhibit "failure to thrive" which includes

poor physical growth and poor health.

C. Studies of attachment

Harry Harlow demonstrated that infant monkeys reared in relative iso-

lation by surrogate artificial mothers do not develop normal mating,

maternal, and social behaviors as adults.

Males may be more affected than females by such isolation.

Young monkeys raised in isolation for less than 6 months can be re-

habilitated by playing with normal young monkeys.

Ren6 Spitz documented that children without proper mothering (e.g.,

those in orphanages) show severe developmental retardation, poor

health, and higher death rates ("hospitalism") in spite of adequate

physical care.

Partly due to such findings, the "foster care" system was established for

young children in the United States who do not have adequate home sit-

uations. "Foster families" are those who have been approved and funded

by the state of residence to take care of a child in their homes.

D. Characteristics of the infant

Reflexive behavior. At birth, the normal infant possesses simple re-

flexes such as the startle reflex (Moro reflex), the palmar grasp reflex,

Babinski's reflex, and the rooting reflex. All of these reflexes disappear

during the first year of life (Table 1-3).

Motor, social, verbal, and cognitive development (Table 1-4)

Although there is a reflexive smile present at birth, the social smile

is one of the first markers of the infant's responsiveness to another in-

dividual.

cable 1-3. Reflexes Present at Birth and the Age at Which They Disappear

Reflex

Description

Age of disappearance

Palmar grasp

The child's fingers grasp objects

2 months

placed in the palm

looting reflex The child's head turns in the

3 months

direction of a stroke on the cheek

as though seeking a nipple

Startle (Moro) reflex

When the child is startled, the

4 months

arms and legs extend

3abinski reflex

Dorsiflexion of the largest toe when

12 months

the plantar surface of the child's

foot is stroked

tracking reflex

The child visually follows a human face

Continues

Chapter 1



The Beginning of Life: Pregnancy through

Preschool



Table 1-4.

Motor, Social, Verbal, and Cognitive Development of the Infant

•

Pulls up to stand



•

Plays social

•

Transfers toys to



games such as

other hand



peek-a-boo,

•

Picks up toys and



waves "bye-bye"

food using "pincer"

(thumb and

forefinger) grasp

11-15 months



•

Walks unassisted



•

Fears separation



•

Says first word

from primary



•

Understands words

caregiver

(separation

anxiety)

Crying and withdrawing in the presence of an unfamiliar person

(stranger anxiety) is normal and begins at about 7 months of age.



This behavior indicates that the infant has developed a specific at

tachment to the mother and is able to distinguish her from a

stranger.

ii.

Infants exposed to many caregivers are less likely to show

stranger anxiety than those exposed to few caregivers.

E. Theories of development

Chess and Thomas showed that there are

endogenous differences

in the temperaments of infants which remain quite stable for the first

25 years of life. These differences include such characteristics as reac-

tivity to stimuli, cyclic behavior patterns such as sleeping, responsive-

ness to people, mood, distractibility, and attention span.

Sigmund Freud described development in terms of the parts of the body

from which the most pleasure is derived at each stage of development

(e.g., the "oral stage" occurs during the first year of life).

Erik Erikson described development in terms of critical periods for the

achievement of social goals; if a specific goal is not achieved at a specific

age, the individual will never achieve the goal. For example, in Erikson's

stage of basic trust versus mistrust, the child must learn to trust oth-

ers during the first year of life or she will never be able to trust others.

Jean Piaget described development in terms of learning capabilities of

the child at each age.

Age

Motor

Skill Area

Social

Verbal and Cognitive

2-3 months

•

Lifts head when

•

Smiles in response

•

Coos or gurgles

lying on stomach

to a human face

(the "social smile")

5-6 months

•

Turns over

•

Forms an attachment

•

Babbles (repeats

•

Sits unassisted

to primary caregiver

single sounds over

•

Grasps with entire

•

Recognizes familiar

and over)

hand ("raking")

people

7-11 months

•

Crawls on hands

•

Shows stranger

•

Imitates sounds

and knees

anxiety

•

Uses gestures

Behavioral Science

IV The Toddler Years: 15 Months to 2V2 Years

Margaret Mahler described early development as a sequential process

of separation of the child from the mother or primary caregiver.

A. Attachment

The major theme of the second year of life is to separate from the

mother or primary caregiver, a process which is complete by about age 3.

There is no evidence that daily separation from working parents in a

good day care setting has short- or long-term negative consequences for

children.

Motor, social, verbal, and cognitive characteristics of the toddler

(see Table 1-4)

The Preschool Child: 2Y to 6 Years

A. Attachment

After reaching 3 years of age a child should be able to spend a few hours

away from the mother in the care of others (e.g., in day care).

A child who cannot do this after age 3 suffers from separation anxiety

disorder (see Chapter 15).

B. Characteristics

The child's vocabulary increases rapidly (Table 1-5) and the child of-

ten finds humor in using "bathroom" profanity (e.g., saying "pee-pee").

The birth of a sibling is likely to occur in the preschool years and sibling

rivalry may occur.

Sibling rivalry or other life stress, such as moving, may result in a child's

use of regression, a defense mechanism in which the child temporarily

behaves in a "babylike" way (e.g., he starts wetting the bed again).

The child can distinguish fantasy from reality (e.g., he knows that imag-

inary friends are not "real" people), although the line between them may

still not be drawn sharply.

Other aspects of motor, social, verbal, and cognitive development of the

preschool child can be found in Table 1-5.

C. Changes at 6 years of age: formation of the conscience

At the end of the preschool years (about age 6), the child's conscience

(the superego of Freud) and sense of morality begin to be developed.

After age 6, the child can put himself in another person's place (empa-

thy) and behave in a caring and sharing way toward others.

Morality and empathy increase further during the school-age years (see

Chapter 2).

Chapter 1

Table 1-5. Motor, Social, Verbal, and Cognitive Development of the Toddler and Preschool Child

The Beginning of Life: Pregnancy through Preschool

Social

Skill Area

Moves away from and then

returns to the mother

for reassurance

("rapprochement")

Shows negativity (e.g.,

the favorite word is "no")

Plays alongside but

not with another

child ("parallel play":

2-4 years of age)

Has a sense of self

as male or female

(gender identity)

Usually achieves bowel and

bladder control

[problems such as

encopresis ("soiling") and

enuresis ("bedwetting")

cannot be diagnosed

until 4 and 5 years of

age, respectively]

Can spend part of the day

with adults other than

parents (e.g., in preschool

setting)

Begins to play cooperatively

with other children

Engages in role playing

(e.g., "I'll be the mommy,

you be the daddy")

May have imaginary

companions

Has curiosity about sex

differences, (e.g., plays

"doctor" with other children)

Has nightmares and transient

phobias (e.g., of "monsters")

Has romantic feelings about

the opposite sex parent

(the "oedipal phase") at

4-5 years of age

Has overconcern about

physical injury at 4-5

years of age

Begins to develop an

internalized moral sense

of right and wrong

Verbal and cognitive

•

Uses about 10

individual words

•

Says own name

Uses about 250 words

Speaks in 2-word

sentences and uses

pronouns (e.g., "me do")

Names body parts and

objects

Uses about 900 words

in speech

Understands about

3,500 words

Speaks in complete

sentences (e.g., "I can

do it myself ")

Shows good verbal self-

expression (e.g., can

tell detailed stories)

Comprehends and uses

prepositions (e.g.,

under, above)

Shows further improve-

ment in verbal and

cognitive skills

•

Begins to think logically

(see Chapter 2)

•

Begins to read

Age

Motor

18 months

•

Throws a ball

•

Stacks 3 blocks

•

Climbs stairs one

foot at a time

•

Scribbles on paper

2 years

•

Kicks a ball

•

Balances on one

foot for one second

•

Stacks 6 blocks

•

Feeds self with

fork and spoon

3 years

Rides a tricycle

Undresses and

partially dresses

without help

Identifies some

colors

Climbs stairs using

alternate feet

Stacks 9 blocks

Cuts paper with

scissors

Copies a circle O

4 years

Catches a ball

with arms

Dresses

independently, using

buttons and zippers

Grooms self (e.g.,

brushes teeth)

Hops on one foot

Copies a cross 0

5 years

Catches a ball with

•

two hands

Draws a person in

detail, (e.g., with

arms, hair, eyes)

•

Skips using alternate

feet

Copies a square 0

6 years

•

Ties shoelaces

•

Rides a 2-wheeled

bicycle

•

Prints letters

•

Copies a triangle A

Directions: Each of the numbered items or incomplete statements in this section is followed by

answers or by completions of the statement. Select the one lettered answer or completion that

is best in each case.

An American couple would like to adopt a

10-month-old Russian child. However, they are

concerned because the child has been in an or-

phanage ever since he was separated from his

birth mother 2 months ago. Which of the fol-

lowing characteristics is the couple most likely

to see in the child at this time?

(A)



Loud crying and protests at the loss of his

mother

(B)



Increased responsiveness to adults

(C)

Normal development of motor skills

(D)

Depression

(E)



Normal development of social skills

Although he previously slept in his own bed,

after his parents separate, a 4-year-old boy in-

sists on sleeping in his mother's bed every

night. He continues to do well in nursery school

and plays well with friends. The best descrip-

tion of this boy's behavior is

(A)



separation anxiety disorder

(B)

normal with regression

(C)

delayed development

(D)



lack of basic trust

(E)

poor superego development

You conduct a well-child checkup on a nor-

mal 2-year-old girl. She is most likely to show

which of the following skills or characteristics?

(A)



Speaks in 2-word sentences

(B)



Is completely toilet trained

(C)

Can comfortably spend most of the day

away from her mother

(D)



Can ride a 2-wheeled bicycle

(E)



Engages in cooperative play

You conduct a well-child checkup on a nor-

mal 4-year-old boy. He is most likely to show

which of the following skills or characteristics?

(A)



Identifies colors

(B)

Reads a 3-word sentence

(C)

Refuses to play with girls

(D)

Ties shoelaces

(E)



Has an internalized moral sense of right

and wrong

Review Test

A mother brings her normal 4-month-old

child to the pediatrician for a well-bat y exam-

ination.

Which of the following developmental

signposts can the doctor expect to be present in

this infant?

(A)



Stranger anxiety

(B)



Social smile

(C)

Rapprochement

(D)

Core gender identity

(E)

Phobias

The overall infant mortality rate in the

United States in 1996 was approximately

(A)



1 per 1000 live births

(B)



3 per 1000 live births

(C)



7 per 1000 live births

(D)



21 per 1000 live births

(E)



40 per 1000 live births

The most important psychological task for a

child between birth and 15 months is the de-

velopment of

(A)



the ability to think logically

(B)

speech

(C)



stranger anxiety

(D)



a conscience

(E)



an intimate attachment to the mother or

primary caregiver

A 28-year-old woman and her husband are

preparing for childbirth by taking a formal

training program. Her physician can expect that

when compared with women who do not take a

formal training program, this woman will expe-

rience

(A)

more medical complications

(B)



longer labor

(C)



closer initial interactions with her infant

(D)

more need for medication during labor

(E)

higher likelihood of postpartum emotional

reactions

Chapter 1



The Beginning of Life: Pregnancy through Preschool

A new mother develops a sad mood 2 days



12. Sitting unassisted

following the birth of her child. Which of the



(A)



0-3 months

following factors is most likely to contribute to



5-6 months

the development of this condition?



( )

(C)



7-10 months

(A)

A positive childbirth experience



(D)



11-15 months

(B)

Breastfeeding



(E)



16-30 months

(C)



Feelings of decreased responsibility

(D)

Changes in hormone levels



13. Showing the rooting reflex

(E) Increased energy



(A)



0-3 months

10.

A well-trained, highly qualified obstetri-



(B)



5-6 months

cian has a busy practice. Which of the follow-



(C)



7-10 months

ing is most likely to be true about postpartum



(D)



11-15 months

reactions in this doctor's patients?



(E)



16-30 months

(A)



Postpartum blues will occur in about 10%

of patients

(B)

Major depression will occur in about 25%

of patients

(C)



Postpartum psychosis will occur in about

8% of patients

(D)

Postpartum psychosis will last about 1

year

(E)



Postpartum blues will last up to one week

Questions 11-16

For each developmental milestone, select the

age at which it commonly first appears.

11.

Crawling on hands and knees

(A)

0-3 months

(B)

5-6 months

(C)



7-10 months

(D)



11-15 months

(E)



16-30 months

14.

Using a "pincer" grasp

(A)



0-3 months

(B)



5-6 months

(C)



7-10 months

(D)



11-15 months

(E)



16-30 months

15.

Using pronouns in speech

(A)

0-3 months

(B)



5-6 months

(C)



7-10 months

(D)



11-15 months

(E)



16-30 months

Answers and Explanations

TBQ-E. Stranger anxiety (the tendency to cry and cling to the mother in the presence of an un-

familiar person) develops in normal infants at 7-9 months of age. It does not indicate that the

child is developmentally delayed, emotionally disturbed, or that the child has been abused, but

rather that the child can now distinguish familiar from unfamiliar people. Stranger anxiety is

seen less frequently in children exposed to many different caregivers.

1-D. This child is likely to show depression at this time. Loud protests occur initially when the

mother leaves the child. With her continued absence of over 2 months and the child's placement

in an orphanage, this child will suffer more serious consequences. These consequences include

depression, decreased responsiveness to adults and deficits in the development of social and mo-

tor skills.

2-B. The best description of this boy's behavior is normal with regression (i.e., a defense mech-

anism involving acting like a child of a younger age). Because he continues to do well in nursery

school and plays well with friends, this is not separation anxiety disorder. There is also no evi-

dence of delayed development, lack of basic trust, or poor superego (conscience) development (see

Chapter 6).

3-A. Two-year-old children speak in 2-word sentences (e.g., "Me go"). Toilet training or the ability

to spend most of the day away from the mother does not usually occur until age 3. Children engage

in cooperative play starting at about age 4 and can ride a 2-wheeled bicycle at about age 6.

4-A. Children can identify some colors by about age 3. The ability to tie shoelaces develops at

about 6 years of age. Having an internalized moral sense of right and wrong (the superego), read-

ing, and preference for playing with children of the same sex are characteristic of latency age

children (7-11 years-See Chapter 2).

5-B. The social smile (smiling in response to seeing a human face) is one of the first developmen-

tal milestones to appear in the infant and is present by 1-2 months of age. Stranger anxiety (fear

of unfamiliar people) appears at about 7 months of age and indicates that the infant has a specific

attachment to the mother. Rapprochement (the tendency to run away from the mother and then

run back for comfort and reassurance) appears at about 16 months of age. Core gender identity (the

sense of self as male or female) is established between 2 and 3 years of age. Transient phobias (ir-

rational fears) occur in normal children, appearing most commonly at 4-6 years of age.

6-C. In 1996, the overall infant mortality rate in the United States was about 7 per 1000 live

births. This rate, which is closely associated with socioeconomic status, was about 14 per 1000

live births in African-American infants and about 6 per 1000 live births in white infants.

7-E. The most important psychological task of infancy is the development of an intimate at-

tachment to the mother or primary caregiver. Stranger anxiety, which normally appears at about

7 months of age, demonstrates that the child has developed this attachment and can distinguish

its

mother from others. Speech, the ability to think logically, and the development of a conscience

are skills which are developed over the first few years of life.

8-C.

Women preparing for childbirth with a formal training program typically experience closer

initial interactions with their infants, equal or lower likelihood of postpartum emotional reac-

tions, shorter labors, fewer medical complications, and less need for medication during labor.

9-D. Changes in hormone levels, fatigue, physical and emotional stresses of childbirth and feelings

of added responsibility contribute to the development of a sad mood in new mothers, otherwise

known as the "baby blues." Breastfeeding usually is not a contributing factor in developing a sad

mood after childbirth.

10-E. Postpartum psychosis is rare, occurring in less than 1% of new mothers and lasting up to

one month after childbirth. Postpartum blues may occur in one third to one half of new mothers,

Chapter 1



The Beginning of Life: Pregnancy through Preschool



and lasts up to one week. Intervention involves support and practical help with the child. Post-

partum depression occurs in 5%-10% of new mothers and is treated primarily with antidepres-

sant medication.

11-C. Crawling on hands and knees commonly begins between 7 and 10 months of age.

12-B. Infants can usually sit unassisted at about 6 months of age.

13-A. The rooting reflex is present at birth.

14-C. The thumb and forefinger "pincer" grasp begins at about 8 months of age. Prior to this, the

child picks up objects using 4 fingers (no thumb) in a raking motion.

5-E. Children start using pronouns (e.g., "me") at about 2 years of age.

School Age, Adolescence,

Special Issues of

Development, and Adulthood

Typical Board Question

A 10-year-old girl with Down syndrome and an IQ of 60 is brought to the physician's office

for a school physical. When the doctor

interviews this girl, he is most

likely to find that she

(A)

has good' self-esteem

(B)

knows

that she

is handicapped

(D) competes successfully with peers

(E) is socially outgoing

(See "Answers

and

Explanations"

end of Chapter)

Latency or School Age: 7-11 Years

A. Motor development. The normal grade school child, 7-11 years of age, en-

gages in complex motor tasks (e.g., plays baseball, skips rope).

B. Social characteristics. The school age child:

Prefers to play with children of the same sex

2. Identifies with the parent of the same sex

Has relationships with adults other than parents (e.g., teachers,

group leaders)

Demonstrates little interest in psychosexual issues

Has internalized a moral sense of right and wrong (conscience) and

understands how to follow rules

C. Cognitive characteristics. The school age child:

1. Is industrious and organized (gathers collections of objects)



Behavioral Science

Has the capacity for logical thought and can determine that objects

have more than one property (e.g., an object can be red and metal)

11.

Adolescence: 11-20 Years

Understands the concept of "conservation." This concept involves the

understanding that a quantity of a substance remains the same re-

gardless of the size of the container it is in (e.g., two containers may con-

tain the same amount of water even though one is a tall, thin tube and

one is a short, wide bowl).

Early adolescence (11-14 years of age)

Puberty occurs in early adolescense and is marked by:

The development of primary and secondary sex characteristics

(Table 2-1) and increased skeletal growth

First menstruation (menarche) in girls, which on average occurs at

11-12 years of age

First ejaculation in boys, which on average occurs at 13-14 years of

age

Cognitive maturation and formation of the personality

Sex drives, which are expressed through physical activity and

masturbation (daily masturbation is normal).

Early adolescents show strong sensitivity to the opinions of peers but are

generally obedient and unlikely to seriously challenge parental authority.

Alterations in expected patterns of development (e.g., acne, obe-

sity, late breast development) may lead to psychological problems.

Middle adolescence (14-17 years of age)

Characteristics

There is great interest in gender roles, body image, and popularity.

Heterosexual crushes (love for an unattainable person such as a rock

star) are common.

Homosexual experiences may occur. Although parents may be-

come alarmed, such practicing is part of normal development.

Efforts to develop an identity by adopting current teen fashion in

Table 2-1. Tanner Stages of Sexual Development

Stage

Characteristics

Genitalia and associated structures are the same as in childhood; nipples, (papillae)

are slightly elevated in girls

Scant, straight pubic hair, testes enlarge, scrotum develops texture; slight elevation

of breast tissue in girls

Pubic hair increases over the pubis and becomes curly, penis increases in length

and testes enlarge

Penis increases in width, glans develops, scrotal skin darkens; areola rises above

the rest of the breast in girls

Male and female genitalia are like adult; pubic hair now is also on thighs, areola is

no longer elevated above the breast in girls

Chapter 2



School Age, Adolescence, Special Issues of Development, and Adulthood



clothing and music and preference for spending time with peers over

family is normal, but may lead to conflict with parents.

Risk-taking behavior

Readiness to challenge parental rules and feelings of omnipotence

may result in risk taking behavior (e.g., failure to use condoms, dri-

ving too fast, smoking).

Education with respect to obvious short term benefits rather than

references to long term consequences of behavior are more likely to

decrease teenagers' unwanted behavior.

-For example, to discourage smoking, telling teenagers that their

teeth will stay white will be more helpful than telling them that they

will avoid lung cancer in 30 years.

C. Late adolescence (17-20 years of age)

Development

Older adolescents develop morals, ethics, self-control and a realis-

tic appraisal of their own abilities; they become concerned with hu-

manitarian issues and world problems.

b. Some adolescents, but not all, develop the ability for abstract reason-

ing (Piaget's stage of formal operations).

2. In the effort to form one's own identity, an identity crisis commonly de-

velops.

a. If the identity crisis is not handled effectively, the adolescent may suf-

fer from role confusion in which he does not know where he belongs

in the world.

b. With role confusion, the adolescent may display behavioral abnor-

malities with criminality or an interest in cults.

D. Teenage sexuality

1. In the United States, first sexual intercourse occurs on average at 16

years of age; by 19 years of age, 80% of men and 70% of women have had

sexual intercourse.

About 65% of teenagers do not use contraceptives for reasons which in-

clude the conviction that they will not get pregnant, lack of access to con-

traceptives, and lack of education about which methods are most effective.

Physicians may counsel minors (persons under 18 years of age) and pro-

vide them with contraceptives without parental knowledge or consent.

E. Teenage pregnancy

Teenage pregnancy is a social problem in the United States. Although the

birth rate and abortion rate in American teenagers are currently

decreasing, teenagers give birth to over 500,000 infants (12,000 of these

infants are born to mothers under 15 years of age) and have about

400,000 abortions annually.

Abortion is legal in the United States. However, in about half of the

states, minors must obtain parental consent for abortion.

Factors predisposing adolescent girls to pregnancy include depression,

poor school achievement, and having divorced parents.



Behavioral Science

4. Pregnant teenagers are at high risk for obstetric complications be-

cause they are less likely to get prenatal care and because they are phys-

ically immature.

III.

Special Issues in Child Development

Illness and death in childhood and adolescence. A child's reaction to

illness and death is closely associated with the child's developmental stage.

During the toddler years (18 months to 2 Y2 years) hospitalized children

fear separation from the parent more than they fear bodily harm, pain,

or death.

During the preschool years (2!~ to 6 years) the child's greatest fear

when hospitalized is of bodily harm.

The preschool-age child does not fully understand the meaning of

death.

b. The child may expect that a dead friend, pet, or relative will come

back to life.

School-age children (7-11 years of age) cope relatively well with hospi-

talization. Thus, this is the best age to perform elective surgery.

Children of this age can understand the finality of death.

4. Ill adolescents may challenge the authority of doctors and nurses and

resist being different than peers. Both of these factors can result in non-

compliance with medical advice.

A child with an ill sibling or parent may respond by acting badly at

school or home [use of the defense mechanism of "acting out" (see Chap-

ter 611)].

B. Adoption

An adoptive parent is a person who voluntarily becomes the legal par-

ent of a child who is not his or her genetic offspring.

2. Adopted children, particularly those adopted after infancy, may be at in-

creased risk for behavioral problems in childhood and adolescence.

Children should be told by their parents that they are adopted at the

earliest age possible to avoid the chance of others telling them first.

Mental retardation

Etiology

The most common genetic cause of mental retardation is Down syn-

drome; the second is Fragile X syndrome.

Other causes include metabolic factors affecting the mother or fetus,

prenatal and postnatal infection and maternal substance abuse;

many cases of mental retardation are of unknown etiology.

Mildly [intelligence quotient (IQ) of 50-69; see Chapter 8] and moderately

(IQ of 35-49) mentally retarded children and adolescents commonly know

they are handicapped. Because of this knowledge, they may become

frustrated and socially withdrawn in part because of poor self-esteem

due to difficulty in communicating and competing with peers.

Chapter 2



School Age, Adolescence, Special Issues of Development, an

dAdulthood



The Vineland Social Maturity Scale can be used to evaluate social

skills and skills for daily living in mentally retarded and other challenged

individuals.

Avoidance of pregnancy in mentally retarded adults can become an is-

sue particularly in residential social settings (e.g., summer camp). Long-

acting, reversible contraceptive methods such as subcutaneous

progesterone implants can be particularly useful for these individuals.

N Early Adulthood: 20-40 Years

A. Characteristics

At about 30 years of age, there is a period of reappraisal of one's life.

The adult's role in society is defined, physical development peaks, and

the adult becomes independent.

B. Responsibilities and relationships

The development of an intimate (e.g., close, sexual) relationship

with another person occurs.

According to Erikson, this is the stage of intimacy versus isolation;

if the individual does not develop the ability to sustain an intimate rela-

tionship by this stage of life, he or she suffers emotional isolation in the

future.

By 30 years of age, most Americans are married and have children.

During their middle thirties, many women alter their lifestyles by re-

turning to work or school or by resuming their careers.

V Middle Adulthood: 40-65 Years

A. Characteristics. The person in middle adulthood possesses more power

and authority than at other life stages.

B. Responsibilities. The individual either maintains a continued sense of

productivity or develops a sense of emptiness (Erikson's stage of genera-

tivity versus stagnation).

C. Relationships

Seventy to eighty percent of men in their middle forties or early fifties ex-

hibit a midlife crisis. This may lead to:

A change in

profession or lifestyle

b. Infidelity, separation, or divorce

c. Increased use of alcohol or drugs

Depression

Midlife crisis is associated with an awareness of one's own aging and

death and severe or unexpected lifestyle changes (e.g., death of a

spouse, loss of a job, serious illness).



Behavioral Science

D. Climacterium is the change in physiologic function that occurs during

midlife.

1. In men, although hormone levels do not change significantly, a decrease

in muscle strength, endurance, and sexual performance (See Chapter 18)

occurs in midlife.

2. In women, menopause occurs.

The ovaries stop functioning, and menstruation stops in the late for-

ties or early fifties.

Absence of menstruation for one year defines the end of menopause.

To avoid unwanted pregnancy, contraceptive measures should be used

until at least one year following the last missed menstrual pe-

riod.

Most women experience menopause with relatively few physical or

psychological problems.

Vasomotor instability, called hot flashes or flushes, is a common

physical problem seen in women in all countries and cultural

groups. It may continue for years and can be relieved by estrogen re-

placement therapy.

Directions: Each of the numbered items or incomplete statements in this section is followed by

answers or by completions of the statement. Select the one lettered answer or completion that

is best in each case.

A mother tells the physician that she is con-

cerned about her son because he consistently

engages in behavior which is dangerous and

potentially life-threatening. The age of her son

most likely to be

(A)



11 years

(B)



13 years

(C)



15 years

(D)



18 years

(E)



20 years

A physician discovers that a 15-year-old pa-

tient is pregnant. Which of the following fac-

tors is likely to have contributed most to her

risk of pregnancy?

(A)



Living in a rural area

(B)

Depressed mood

(C)



Intact parental unit

(D)

Achievement in school

(E)

Education about contraceptive methods

A 50-year-old male patient comes in for an

insurance physical. Which of the following de-

velopmental signposts is most likely to charac-

terize this man?

(A)



Decreased alcohol use

(B)

Peak physical development

(C)

Possession of power and authority

(D)



Strong resistance to changes in social re-

lationships

(E)

Strong resistance to changes in work re-

lationships

A woman has recently gone through meno-

pause. Which of the following is most likely to

characterize this transition?

(A)

Sudden onset of symptoms

(B)



Cessation of menstruation

(C)



Severe depression

(D)

Severe anxiety

(E)



Occurrence in the fourth decade of life

5. Increase in penis width, development of the

glans, and darkening of scrotal skin character-

ize Tanner stage

(A)

(B)

(C)

(D) 4

(E)

Review Test

The adoptive parents of a newborn ask their

physician when they should tell the child that

she is adopted. The pediatrician correctly sug-

gests that they tell her

(A)

when she questions them about her back-

ground

(B)



when she enters school

(C)



as soon as possible

(D)



at 4 years of age

(E) if she develops an illness that has a

known genetic basis

A physician is conducting a school physical

on a normal 10-year-old girl. When interview-

ing the child, the physician is most likely to

find which of the following psychological char-

acteristics?

(A)

Lack of conscience formation

(B)



Poor capacity for logical thought

(C)



Identification with her father

(D)

Relatively stronger importance of friends

over family when compared to children of

younger ages

(E)

No preference with respect for the sex of

playmates

A child's pet has recently died. The child be-

lieves that the pet will soon come back to life.

This child is most likely to be age

(A)



4 years

(B)



6 years

(C)



7 years

(D)



9 years

(E)



11 years

A 5-year-old boy requires surgery to correct

inguinalhernia. When the child enters the

hospital to have surgery, his greatest fear is

likely to be

(A)



separation from his mother

(B)

the unknown environment

(C)

the possibility that he will die during

surgery

(D)

unfamiliar people

(E)



damage to his body

Answers and Explanations

TBQ-B. Mildly and moderately mentally retarded children are aware that they have a handi-

cap. They often have low self-esteem and may become socially withdrawn. In part, these prob-

lems occur because they have difficulty communicating with and competing with peers.

1-C. The age of this woman's son is most likely to be 15 years. Middle adolescents (14-17 years)

often challenge parental authority and have feelings of omnipotence (i.e., nothing bad will hap-

pen to them because they are all-powerful). Younger adolescents are unlikely to challenge

parental rules and authority. Older adolescents (18-20 years) have developed self-control and a

more realistic picture of their own abilities.

2-B. Teenagers who become pregnant frequently are depressed, come from homes where the par-

ents are divorced, have problems in school, and may not know about effective contraceptive meth-

ods. Studies have not indicated that living in a rural area is related to teenage pregnancy.

3-C.



While midlife is associated with the possession of power and authority, physical abilities

decline. This time of life is also associated with a midlife crisis which may include increased al-

cohol and drug use as well as an increased likelihood of changes in social and work relationships.

4-B.

Menopause is characterized by cessation of menstruation. Most women go through

menopause gradually at about 50 years of age and with few psychological or physical problems.

5-D. Increase in penis width, development of the glans and darkening of scrotal skin character-

ize Tanner stage 4. Stage 1 is characterized by slight elevation of the papillae, and stage 2 by the

presence of scant, straight pubic hair, testes enlargement, development of texture in scrotal skin,

and slight elevation of breast tissue. In stage 3, pubic hair increases over the pubis and becomes

curly, and the penis increases in length; in stage 5 male and female genitalia are much like those

of the adult.

6-C. The best time to tell a child she is adopted is as soon as pos:aible, usually when the child can

first understand language. Waiting any longer than this will increase the probability that some-

one else will tell the child before the parents are able to.

7-D.

When compared to younger ages, peers and non-familial adults become more important to

the latency age child and the family becomes less important. Children 7-11 years of age have the

capacity for logical thought, have a conscience, identify with the same-sex parent, and show a

strong preference for playmates of their own sex.

8-A. Preschool children usually cannot comprehend the meaning of death and commonly believe

that the dead person or pet will come back to life. Children over the age of 6 years commonly are

aware of the finality of death.

9-E. The greatest fear of the preschool child is damage to his body. Children younger than age 3

are more fearful of separation from parents, an unknown environment and unfamiliar people.

Fear of death is more prominent in older children who understand that death is not temporary.

Aging, Death,

and Bereavement

Typical

Board

Question

An 80-year-old patient tells you that she is concerned because she forgets the addresses of

people she

has

just met

and

takes longer than in the past to do the Sunday crossword puz-

zle. She enjoys family visits, lives comfortably on her own,

and shops and' cooks for

herself.

This patient

(A)

probably showing normal aging

(B)

probably suffering from Alzheimer's disease

(D) is likely to develop an anxiety disorder

(E)

should be advised

not to live alone

(See "Answers and Explanations" at end of Chapter)

Aging

A. Demographics

By 2020, over 15% of the United States population will be more than 65

years of age.

The fastest growing segment of the population is people over age 85.

The average life expectancy in the United States is currently about 76

years; however, this figure varies greatly by gender and race (Table 3-1).

Differences in life expectancies by gender and race have been decreasing

over the past few years.

Gerontology, the study of aging, and geriatrics, the care of aging peo-

ple, have become important new medical fields.

B. Somatic and neurologic changes

Strength and physical health gradually decline. This decline shows

great variability, but commonly includes impaired vision, hearing, and im-

mune responses; decreased muscle mass and strength; increased fat de-

posits; osteoporosis; decreased renal, pulmonary, and gastrointestinal func-



Behavioral Science

Table 3-1. Life Expectancy (in Years) at Birth in the United States by Sex and Race

(1996

for

African-American and White American;

1990

for Native American and Asian

American)

African-American



Native American White American



Asian American

Men



Women



tion, reduced bladder control, and decreased responsiveness to changes in

ambient temperature.

Changes in the brain occur with aging.

These changes include decreased weight, enlarged ventricles

and sulci, and decreased cerebral blood flow.

b. Senile plaques and neurofibrillary tangles are present in the

normally aging brain but to a lesser extent than in dementia

of the Alzheimer's type.

Cognitive changes

Although learning speed may decrease, in the absence of brain disease,

intelligence remains approximately the same throughout life.

Slight memory problems may occur in normal aging, (e.g., the patient

may forget the name of a new acquaintance). However, these problems

do not interfere with the patient's functioning and he is able to live

independently.

D. Psychological changes

1. In late adulthood there is either a sense of ego integrity, (i.e., satisfaction,

and pride in one's past accomplishments) or a sense of despair and worth-

lessness (Erikson's stage of ego integrity versus despair). Many el-

derly people achieve ego integrity.

Psychopathology and related problems

Depression is the most common psychiatric disorder in the el-

derly. Suicide is more common in the elderly than in the general

population.

(1) Factors associated with depression in the elderly include loss of

spouse, other family members, and friends; decreased social sta-

tus; and decline of health.

(2)

Depression may mimic and thus be misdiagnosed as

Alzheimer's disease. This misdiagnosed disorder is re-

ferred to as pseudodementia because it is associated with

memory loss and cognitive problems (see Chapter 14)

(3) Depression can be treated successfully with supportive psy-

chotherapy in conjunction with pharmacotherapy or electrocon-

vulsive therapy (see Chapter 15).

b. Sleep patterns change, resulting in loss of sleep, poor sleep quality,

or both (see Chapter 10).

Anxiety and fearfulness may be associated with realistic fear-inducing

situations (e.g., worries about developing a physical illness or falling

and breaking a bone).

Alcohol-related disorders are often unidentified but are present in

10%-15% of the geriatric population.

Chapter 3



Aging, Death, and Bereavement



Psychoactive agents may produce different effects in the elderly

than in younger patients.

E. Longevity has been associated with many factors, including:

Family history of longevity

Continuation of physical and occupational activity

Advanced education

Social support systems, including marriage

II.

Stages of Dying And Death.

According to Elizabeth Kübler-Ross, the process of dying involves five

stages. The stages usually occur in the following order, but also may be present

simultaneously or occur in another order.

A. Denial. The patient refuses to believe that she is dying ("The laboratory

made an error").

B. Anger. The patient may become angry at the physician and hospital staff ("It

is your fault that I am dying. You should have checked on me weekly"). Physi-

cians must learn not to take such comments personally (see also Chapter 21).

C. Bargaining. The patient may try to strike a bargain with God or some higher

being ("I will give half of my money to charity if I can get rid of this disease").

D. Depression. The patient becomes preoccupied with death and may become

emotionally detached ("I feel so distant from others and so hopeless").

Acceptance. The patient is calm and accepts her fate ("I am ready to go

now").

III. Bereavement (Normal Grief) Versus Depression (Abnormal

Grief).

After the loss of a loved one, there is a normal grief reaction. This reaction also

occurs with other losses, such as loss of a body part, or, for younger people, with

a miscarriage or abortion. A normal grief reaction must be distinguished from

depression, which is pathologic.

A. Characteristics of normal grief (bereavement)

Grief is characterized initially by shock and denial.

2. In normal grief, the bereaved may experience an illusion (see also Table

11-1) that the deceased person is physically present.

Normal grief generally subsides after 1-2 years, although some features

may continue longer. Even after they have subsided, symptoms may re-

turn on holidays or special occasions (the "anniversary reaction").

4. The mortality rate is high for close relatives (especially widowed

men) in the first year of bereavement.

B. Comparison between normal and abnormal grief reactions can be

found in Table 3-2.



Behavioral Science

Table 3-2. Comparison between Normal Grief Reactions and Abnormal Grief Reactions

Normal grief reaction (Bereavement)

Minor weight loss (e.g., 1-3 pounds)

Minor sleep disturbances

Some guilty feelings

Illusions (thinking that one briefly

sees the deceased person)

Attempts to return to work and social activities

Cries and expresses sadness

Severe symptoms resolve within 2 months

Moderate symptoms subside within 1 year

Treatment includes increased calls and

visits to the physician, supportive

psychotherapy, and short-acting

benzodiazepines for temporary

problems with sleep

(

Adapted from Fadem B, Simring S:

High Yield Psychiatry.

Baltimore,

Williams

& Wilkins, 1998, p 31.)

C. Physician's response to death

Abnormal

grief reaction (Depression)

Significant weight loss (e.g., > 8 pounds)

Significant sleep disturbances

Intense feelings of guilt and worthlessness

Hallucinations and delusions (hearing the

dead person talking)

Resumes few, if any, work or social activities

Considers or attempts suicide

Severe symptoms persist for > 2 months

Moderate symptoms persist for > 1 year

Treatment includes antidepressants,

antipsychotics, or electroconvulsive

therapy

The major responsibility of the physician is to give support to the

dying patient and the patient's family.

Generally, physicians make the patient completely aware of the di-

agnosis and prognosis. However, a physician should follow the patient's

lead as to how much he or she wants to know about the condition. With

the patient's permission, the physician may tell the family the diag-

nosis and other details of the illness (see Chapter

23).

Physicians often feel a sense of failure at not preventing death. They may

deal with this sense by becoming emotionally detached from the patient

in order to deal with his imminent death. Such detachment can preclude

helping the patient and family through this important transition.

A 70-year-old patient whose wife died 8

months ago reports that he sometimes wakes

up an hour earlier than usual and often cries

when he thinks about his wife. He also tells

you that on one occasion he briefly followed a

woman down the street who resembled his late

wife. The patient also relates that he has re-

joined his bowling team and enjoys visits with

his grandchildren. For this patient, the best

recommendation of the physician is

(A)



medication for sleep

(B)

antidepressant medication

(C)



regular phone calls and visits to "check in"

with the doctor

(D)

psychotherapy

(E)

a neuropsychological evaluation for

Alzheimer's disease

A 70-year-old patient whose wife died 8

months ago appears unshaven and disheveled.

He has lost 11 pounds, has persistent problems

sleeping and has no interest in interacting

with friends and family. For this patient, the

best recommendation of the physician is

(A)



medication for sleep

(B)

antidepressant medication

(C)



regular phone calls and visits to "check in"

with the doctor

(D)

psychotherapy

(E)

a neuropsychological evaluation for Alz-

heimer's disease

An 80-year-old man is brought to a clinic by

his wife who complains that he has become for-

getful since he voluntarily gave up his driver's

license one month previously. Which of the fol-

lowing statements best describes this patient?

(A)

He probably has Alzheimer's disease

(B)



He is probably suffering from depression

(C)

He is at decreased risk of suicide when

compared with a younger man in the same

situation

(D)

He cannot be treated effectively with psy-

choactive drugs

(E)



He probably has a decreased intelligence

quotient (IQ)

Review Test

Directions: Each of the numbered items or incomplete statements in this section is followed by

answers or by completions of the statement. Select the one lettered answer or completion that

is best in each case.

A terminally ill patient who uses a state-

ment such as, "It is the doctor's fault that I be-

came ill; she didn't do an electrocardiogram

when I came for my last office visit," is most

likely in which stage of dying, according to

Elizabeth Kübler-Ross?

(A)

Denial

(B)

Anger

(C)

Bargaining

(D)

Depression

(E)

Acceptance

A physician conducts a physical examination

on an active, independent 75-year-old woman.

Which of the following findings is most likely?

(A) Increased immune responses

(B)



Increased muscle mass

(C)



Decreased size of brain ventricles

(D)

Decreased bladder control

(E)

Severs memory problems

Ninety percent of the patients in a primary

care physician's practice are over 65 years of

age. When compared to the general population,

these elderly patients are more likely to show

which of the following psychological character-

istics?

(



Lower likelihood of suicide

(B)

Less anxiety

(C)



Lower intelligence

(D)

Poorer sleep quality

(E)



Less depression

The 78-year-old husband of a 70-year-old

woman has just died. If this woman experi-

ences normal bereavement, which of the fol-

lowing responses would be expected?

(A)



Initial loss of appetite

(B)



Feelings of worthlessness

(C)



Threats of suicide

(D)



Grief lasting 3-4 years after the death

(E)



Feelings of hopelessness

2 6



Behavioral Science

A physician has just diagnosed a case of

terminal pancreatic cancer in a 68-year-old

man. Which of the following statements re-

garding the reactions and behavior of the

physician is the most true?

(A)



She should inform the family, but not the

patient, about the serious nature of the

illness.

(B)



Her involvement with the patient's fam-

ily should end when he dies.

(C)

She should provide strong sedation for

family members when the patient dies

until the initial shock of his death wears

off.

(D)



She will feel that she has failed when the

patient dies.

(E)

She will feel closer and closer to the pa-

tient as his death approaches.

The average difference in life expectancy

between white women and African-American

men is approximately

(A)



3 years

(B)



6 years

(C)



10 years

(D)



14 years

(E)



20 years

Answers and Explanations

TBQ-A.

This 80-year-old woman is probably showing normal aging, since she can function well

living alone. Minor memory loss which does not interfere with normal functioning such as she

describes is typically seen in normally aging people. There is no evidence that this patient is suf-

fering from Alzheimer's disease, depression, or an anxiety disorder.

1-C. This patient whose wife died 8 months ago is showing a normal grief reaction. Although he

sometimes wakes up an hour earlier than usual and cries when he thinks about his wife, he is

showing efforts to return to his lifestyle by rejoining his bowling team and visiting with his fam-

ily.

The illusion of believing he sees and thus follows a woman who resembled his late wife is seen

in a normal grief reaction. For a normal grief reaction, recommending regular phone calls and

visits to "check in" with the doctor is the appropriate intervention. Sleep medication, antide-

pressants, psychotherapy, and a neuropsychological evaluation are not necessary for this patient.

2-B. This patient whose wife died 8 months ago demonstrates an abnormal grief reaction. He is

showing signs of depression (i.e., poor grooming, significant weight loss, serious sleep problems,

and no interest in interacting with friends and family) (see Chapter 12). For this patient, the

physician should recommend antidepressant medication (see Chapter 15). Psychotherapy, while

helpful, will be less useful than medication for this patient. His sleep will improve as the de-

pression improves. There is no indication that this patient needs a neuropsychological evalua-

tion for Alzheimer's disease.

3-B. Depression is commonly seen in elderly patients and memory problems are often seen in

depression. Thus, depression in the elderly may mimic Alzheimer's disease (pseudodementia).

The sudden onset of the condition with the concurrent loss of an important sign of youth and in-

dependence (the driver's license) indicate that the patient is likely to be suffering from depres-

sion rather than Alzheimer's disease. He can be treated effectively for depression with psy-

choactive drugs (i.e., antidepressants). This depressed patient is at increased risk of suicide when

compared with a younger man in the same situation.

4-B. During the anger stage of dying, the patient is likely to blame the physician.

5-D. Of the listed findings, decreased bladder control is the most likely finding in the examina-

tion of an active, independent 75-year-old woman. In aging, immune responses and muscle mass

decrease and brain ventricles increase in size. While mild memory problems may occur, severe

Chapter 3



Aging, Death, and Bereavement



memory problems do not occur in normal aging. Severe memory problems which interfere with

normal function indicate the development of a dementia like Alzheimer's disease.

6-D. Sleep disturbances, such as decreased delta or slow wave sleep (see Chapter 10), commonly

occur in the elderly. Suicide and depression are more common in the elderly than in the general

population. Anxiety may arise easily due to fears of illness and injury. Intelligence does not de-

crease with age in normal people.

7-A. Initial loss of appetite is common in normal bereavement. Feelings of worthlessness or

hopelessness, threats of suicide, and an extended period of grief characterize depression rather

than normal bereavement.

8-D. Physicians often feel that they have failed when a patient dies. Rather than becoming

closer, this physician may become emotionally detached from the patient in order to deal with

his impending death. Heavy sedation is rarely indicated as treatment for the bereaved because

may interfere with the grieving process. Generally, physicians inform patients when they have

a terminal illness and provide an important source of support for the family before and after the

patient's death.

9-D. The difference in life expectancy between white women (80 years) and African-American

men (66 years) is approximately 14 years. The difference in life expectancy by age and sex is cur-

rently decreasing.

Genetics, Anatomy, and

Biochemistry of Behavior

Typical Board Question

A 28-year-old male patient is brought to the emergency room after a fight in-which' he at-

tacked a man who cut into his line at the supermarket checkout. In the emergency room

he remains assaultive and combative. The body fluids of this patient are most likely to show

(A) increased 3-methoxy-4-hydroxyphenylglycol (MHPG)

(B) decreased MHPG

(D) decreased 5-HIAA

(E) decreased homovanillic acid (HVA)

(See "Answers and Explanations" at end of Chapter)

Genetics

A. There is a genetic component to the etiology of a variety of psychiatric dis-

orders (e.g., schizophrenia, mood disorders, neuropsychiatric disorders, per-

sonality disorders, alcoholism), and personality traits.

B. Studies for examining the genetics of behavior

Pedigree studies use a family tree to show the occurrence of behavior

disorders and traits within a family.

Family risk studies compare how frequently a behavioral disorder or

trait occurs in the relatives of the affected individual (proband) with

how frequently it occurs in the general population.

Twin studies

a. Adoption studies using monozygotic twins (who are derived from

a single fertilized ovum) or dizygotic twins (who are derived from

two fertilized ova) reared in different homes, are used to differentiate

the effects of genetic factors from environmental factors in the occur-

rence of psychiatric disorders.

3 0



Behavioral Science

II.

Neuroanatomy

b. If there is a genetic component to the etiology, a disorder may be ex-

pected to have a higher concordance rate in monozygotic twins

than in dizygotic twins (i.e., if concordant, the disorder occurs in both

twins).

-The human nervous system consists of the central nervous system (CNS)

and the peripheral nervous system (PNS).

The CNS contains the brain and spinal cord.

The cerebral cortex of the brain can be divided

-Anatomically into four lobes: frontal, temporal, parietal, and occipital

-By arrangement of neuron layers or cryoarchitecture

-Functionally into motor, sensory, and association areas

The cerebral hemispheres

The hemispheres are connected by the corpus callosum, anterior

commissure,

hippocampal commissure,

and habenular

commissure.

The functions of the hemispheres are lateralized.

(1) The right, or nondominant hemisphere is associated primar-

ily with perception; it also is associated with spatial relations,

body image, and musical and artistic ability.

(2) The left, or dominant, hemisphere is associated with lan-

guage function in about 96% of right-handed people and 70% of

left-handed people.

Sex differences in cerebral lateralization. Women may have a

larger corpus callosum and anterior

commissure

and appear to have

better interhemispheric communication than men. Men may have bet-

ter-developed right hemispheres and appear to be better at spatial

tasks than women.

Brain lesions caused by accident, disease, or surgery are associated

with particular neuropsychiatric effects (Table 4-1).

B. The PNS contains all sensory, motor, and autonomic fibers outside of the

CNS including the spinal nerves, cranial nerves, and peripheral gan-

glia.

The PNS carries sensory information to the CNS, and carries motor in-

formation away from the CNS.

The autonomic nervous system, which consists of sympathetic and

parasympathetic divisions, innervates the internal organs.

The autonomic nervous system coordinates emotions with visceral re-

sponses such as heart rate, blood pressure, and peptic acid secretion.

Visceral responses occurring as a result of psychological stress are in-

volved in the development and exacerbation of some physical illnesses

(see Chapter 22).

Chapter 4

Table 4-1. Neuropsychiatric Effects of Brain Lesions

Adapted from Fadem B,

High-Yield Behavioral Science.

Baltimore,

Williams

& Wilkins, 1996. Table 9-l, p. 32.

IIf.

Neurotransmission

Genetics, Anatomy, and Biochemistry of Behavior



A. Synapses and neurotransmitters

1. Information in the nervous system is transferred across synaptic cleft

(i.e., the space between the axon terminal of the presynaptic neuron and

the dendrite of the postsynaptic neuron).

When the presynaptic neuron is stimulated, a neurotransmitter is re-

leased, travels across the synaptic cleft, and acts on receptors on the post-

synaptic neuron.

-Neurotransmitters are excitatory if they increase the chances that

a neuron will fire and inhibitory if they decrease these chances.

B. Presynaptic and postsynaptic receptors are proteins present in the

membrane of the neuron that can recognize specific neurotransmitters.

Location of Lesion

Effects of Lesion on the Patient

Temporal lobes

Impaired memory; psychomotor seizures

Inability to understand language [i.e. Wernicke's aphasia

(left-side lesions)]

Limbic system

Hippocampus

Poor new learning

Implicated specifically in dementia of the

Alzheimer type

Amygdala

Changes in aggressive behavior, increased sexual behavior,

hyperorality; (Khiver-Bucy syndrome)

Decreased fear response

Problems recognizing the meaningfulness of visual cues

(visual agnosia)

Hypothalamus

Hunger leading to obesity (ventromedial nucleus damage);

loss of appetite leading to weight loss (lateral

nucleus damage)

Effects on sexual activity and body temperature regulation

Frontal lobes

Mood disorders [i.e., depression (especially left-side lesions)]

Problems with motivation, concentration, attention,

orientation, and behavior

Inability to speak fluently, [i.e., Broca's aphasia (left-side

lesions)]

Parietal lobes

•

Impaired processing of visual-spatial information, [i.e.,

cannot copy a simple line drawing or a clock face correctly

(right-sided lesions)]

•

Impaired processing of verbal information [i.e., cannot name

fingers, cannot write (left-sided lesions)]

Occipital lobes

•

Visual hallucinations and illusions

•

Inability to identify camouflaged objects

•

Blindness

Reticular system

•

Changes in sleep-wake mechanisms

Basal ganglia

•

Disorders of movement [i.e., Parkinson's disease (substantia

nigra), Huntington's disease (caudate and putamen) and

Tourette syndrome (caudate)]



Behavioral Science

'sychiatric

;ondition

)epression

Mania

chizophrenia

Lnxiety

)ementia of the

Alzheimer type

The changeability of number or affinity of receptors for specific neuro-

transmitters (neuronal plasticity) can regulate the responsiveness of

neurons.

Second messengers. When stimulated by neurotransmitters, postsyn-

aptic receptors may alter the metabolism of neurons by the use of second

messengers, which include cyclic adenosine monophosphate (CAMP),

lipids (e.g., diacylglycerol), and Cat+.

C. Classification of neurotransmitters. The biogenic amines

(

mono-

amines),

amino acids, and peptides are the three major classes of neuro-

transmitters.

D. Regulation of neurotransmitter activity

The concentration of neurotransmitters in the synaptic cleft is closely re-

lated to mood and behavior. A number of mechanisms affect this concen-

tration.

After release by the presynaptic neuron, neurotransmitters are removed

from the synaptic cleft by:

Reuptake by the presynaptic neuron

Degradation by enzymes such as

monoamine

oxidase (MAO)

Availability of specific neurotransmitters is associated with common psy-

chiatric conditions (Table 4-2).

[

V Biogenie Amines

A. Overview

The biogenic amines, or

monoamines,

include catecholamines, in-

dolamines, ethylamines, and quaternary amines.

The

monoamine

theory of mood disorder hypothesizes that lowered

monoamine

activity results in depression.

Metabolites of the

monoamines

are often measured in psychiatric re-

search and diagnosis because they are more easily measured in body flu-

ids than the actual

monoamines

(Table 4-3).

B. Dopamine

Dopamine, a catecholamine, is involved in the pathophysiology of schiz-

ophrenia, Parkinson disease, mood disorders, the conditioned fear

response (see Chapter 7), and the "rewarding" nature of drugs of abuse

(see Chapter 9).

'able 4-2. Psychiatric Conditions and Associated Neurotransmitter

Activity

Neurotransmitter Activity Increased (T) or Decreased (1)

Norepinephrine (1), serotonin (1), dopamine (1)

Dopamine (T)

Dopamine (T), Serotonin (T)

y-aminobutyric acid (GABA) (1), serotonin (1), norepinephrine (T)

Acetylcholine (1)

dapted from Fadem B:

High-Yield Behavioral Science.

Baltimore,

Williams

& Wilkins, 1996, Table 9-2, p. 32.

Chapter 4

Table 4-3. Metabolites of

Monoamines

and Associated Psychopathology

Increased (T) or Decreased (1)

Concentration of Metabolite

in Blood Plasma, Cerebrospinal

Neurotransmitter



Fluid or Urine

Dopamine



(T) HVA (homovanillic acid)

Norepinephrine

Serotonin

(1)

HVA

Genetics, Anatomy, and Biochemistry of Behavior



(T) VMA (vanillylmandelic acid)

(1)

MHPG

(3-methoxy-

hydroxyphenylglycol)

(1)

5-HIAA (5-hydroxyindoleacetic acid)

Associated

Psychopathology

Schizophrenia and other

conditions involving

psychosis (see Chapters 9,

11 and 12)

Parkinson's disease

Patients treated with

antipsychotic agents

Depression

Adrenal medulla tumor

(pheochromocytoma)

Severe depression and

attempted suicide

Severe depression and

attempted suicide

Aggressiveness and violence

Impulsiveness

Fire setting

Tourette syndrome

Alcohol abuse

Bulimia

Adapted from Fadem B:

High-Yield Behavioral Science.

Baltimore, Williams & Wilkins, 1996, Table 9-3,p. 33.

Synthesis. The amino acid tyrosine is converted to the precursor for

dopamine by the enzyme tyrosine hydroxylase.

Dopaminergic tracts

The nigrostriatal tract is involved in the regulation of muscle tone

and movement.

(1) This tract degenerates in Parkinson's disease.

(2) Treatment with antipsychotic drugs, which block postsynaptic

dopamine receptors receiving input from the nigrostriatal tract,

can result in parkinsonism-like symptoms.

Dopamine acts on the tuberoinfundibular tract to inhibit the se-

cretion of prolactin from the anterior pituitary.

(1) Blockade of dopamine receptors by antipsychotic drugs prevents

the inhibition of prolactin release and results in elevated pro-

lactin levels.

(2) This elevation in turn results in symptoms such as breast en-

largement, galactorrhea, and sexual dysfunction.

The mesolimbic-mesocortical tract may have a role in expression

of mood since it projects into the limbic system, which is involved in

emotional behavior.

C. Norepinephrine, a catecholamine, plays a role in mood, anxiety, arousal,

learning, and memory.

Synthesis

Increased (T) or Decreased (1)

Concentration of Metabolite

in Blood Plasma, Cerebrospinal

Neurotransmitter



Fluid or Urine

Dopamine



(T) HVA (homovanillic acid)

Norepinephrine

Serotonin

(1)

HVA

Genetics, Anatomy, and Biochemistry of Behavior



Chapter 4

Table 4-3. Metabolites of

Monoamines

and Associated Psychopathology

(T) VMA (vanillylmandelic acid)

(.l)

MHPG

(3-methoxy-

hydroxyphenylglycol)

(1)

5-HIAA (5-hydroxyindoleacetic acid)

Associated

Psychopathology

Schizophrenia and other

conditions involving

psychosis (see Chapters 9,

11 and 12)

Parkinson's disease

Patients treated with

antipsychotic agents

Depression

Adrenal medulla tumor

(pheochromocytoma)

Severe depression and

attempted suicide

Severe depression and

attempted suicide

Aggressiveness and violence

Impulsiveness

Fire setting

Tourette syndrome

Alcohol abuse

Bulimia

Adapted from Fadem B:

High-Yield Behavioral Science.

Baltimore,

Williams

& Wilkins, 1996, Table 9-3, p. 33.

Synthesis. The amino acid tyrosine is converted to the precursor for

dopamine by the enzyme tyrosine hydroxylase.

Dopaminergic tracts

The nigrostriatal tract is involved in the regulation of muscle tone

and movement.

(1) This tract degenerates in Parkinson's disease.

(2)

Treatment with antipsychotic drugs, which block postsynaptic

dopamine receptors receiving input from the nigrostriatal tract,

can result in parkinsonism-like symptoms.

Dopamine acts on the tuberoinfundibular tract to inhibit the se-

cretion of prolactin from the anterior pituitary.

(1)

Blockade of dopamine receptors by antipsychotic drugs prevents

the inhibition of prolactin release and results in elevated pro-

lactin levels.

(2) This elevation in turn results in symptoms such as breast en-

largement, galactorrhea, and sexual dysfunction.

The mesolimbic-mesocortical tract may have a role in expression

of mood since it projects into the limbic system, which is involved in

emotional behavior.

C. Norepinephrine, a catecholamine, plays a role in mood, anxiety, arousal,

learning, and memory.

Synthesis



Behavioral Science

Like dopaminergic neurons, noradrenergic neurons synthesize do-

pamine.

Dopamine [3-hydroxylase, present in noradrenergic neurons, converts

this dopamine to norepinephrine.

Localization. Most noradrenergic neurons (approximately 10,000 per

hemisphere in the brain) are located in the locus ceruleus.

D. Serotonin, an indolamine, plays a role in mood, sleep, sexuality, and im-

pulse control; elevation of serotonin is associated with improved mood

and sleep but decreased sexual function (particularly delayed orgasm).

Decreased serotonin is associated with poor impulse control, depression,

and poor sleep.

Synthesis. The amino acid tryptophan is converted to serotonin [also

known as 5-hydroxytryptamine (5-HT)] by the enzyme tryptophan hy-

droxylase as well as by an amino acid decarboxylase.

Localization. Most serotonergic cell bodies in the brain are contained in

the dorsal raphe nucleus.

Antidepressants and serotonin

-Heterocyclic antidepressants, selective serotonin reuptake in-

hibitors, and MAO inhibitors ultimately increase the presence of sero-

tonin and norepinephrine in the synaptic cleft.

Heterocyclics block reuptake of serotonin and norepinephrine, and

selective serotonin reuptake inhibitors such as fluoxetine [Prozac]

selectively block reuptake of serotonin by the presynaptic neuron.

MAO inhibitors prevent the degradation of serotonin and norep-

inephrine by MAO.

E. Histamine

Histamine, an ethylamine, is affected by psychoactive drugs.

Histamine receptor blockade with drugs such as antipsychotics and tri-

cyclic antidepressants is associated with common side effects of these

drugs such as sedation and increased appetite leading to weight gain.

Acetylcholine (ACh), a quaternary amine, is the transmitter used by

nerve-skeleton-muscle junctions.

Degeneration of cholinergic neurons is associated with dementia

of the Alzheimer type, Down syndrome, and movement and sleep

disorders.

Cholinergic neurons synthesize ACh from acetyl coenzyme A and

choline

using

choline

acetyltransferase.

Acetylcholinesterase (ACNE) breaks ACh down into

choline

and acetate.

Blocking the action of AChE with drugs such as tacrine [Cognex] and

donepezil [Aricept] can delay the progression of dementia of the Alzheimer

type but cannot reverse lost function.

Blockade of muscarinic Ach receptors with drugs such as antipsy-

chotics and tricyclic antidepressants results in the classic "anticholiner-

gic" adverse effects seen with use of these drugs, including dry mouth,

blurred vision, urinary hesitancy, and constipation.

Chapter 4



Genetics, Anatomy, and Biochemistry of Behav

ior



V Amino Acid Neurotransmitters

-These neurotransmitters are involved in most synapses in the brain, and in-

clude y-aminobutyric acid (GABA),

glycine,

and glutamate.

GABA

GABA is the principal inhibitory neurotransmitter in the CNS.

GABA is closely involved in the action of the antianxiety agents, benzo-

diazepines (e.g., diazepam [Valium]) and barbiturates (e.g., secobarbital

[Seconal]).

-Benzodiazepines and barbiturates increase the affinity of GABA for

its binding site, allowing more chloride to enter the neuron. The chlo-

ride-laden neurons become hyperpolarized and inhibited, decreasing

neuronal firing and ultimately decreasing anxiety.

Glycine

is an inhibitory neurotransmitter which works on its own and as a

regulator of glutamate activity.

C. Glutamate is an excitatory neurotransmitter and may be associated with

epilepsy, schizophrenia, neurodegenerative illnesses and mecha-

nisms of cell death.

VI.

Neuropeptides

A. Endogenous opioids

Enkephalins and endorphins are opioids produced by the brain itself

that decrease pain and anxiety and have a role in addiction and mood.

Placebo effects (see also Chapter 25) may be mediated by the endoge-

nous opioid system. Prior treatment with an opiate receptor blocker such

as naloxone may block the placebo effect.

B. Other neuropeptides have been implicated in the following conditions.

Schizophrenia [cholecystokinin (CCK) and neurotensin]

Mood disorders [somatostatin, substance P, vasopressin, oxytocin, and

vasoactive intestinal peptide (VIP)]

Huntington disease (somatostatin and substance P)

Dementia of the Alzheimer type (somatostatin and VIP)

Anxiety disorders and substance P (CCK)

Pain and aggression (substance P)

Analysis of the blood plasma of a 45-year-old

male patient shows an increased level of ho-

movanillic acid (HVA). This patient is most

likely to show which of the following conditions?

(A)



Parkinson's disease

(B)

Depression

(C)

Bulimia

(D)

Pheochromocytoma

(E)

Schizophrenia

A very anxious patient is examined in the

emergency room. If it could be measured, the

y-aminobutyric acid (GABA) activity in the

brain of this patient would most likely be

(A) increased

(B)

decreased

(D)

higher than the activity of serotonin

(E)

higher than the activity of norepinephrine

3. In a clinical experiment, a 48-year-old female

patient with chronic pain who, in the past, has

responded to placebos is given naloxone.

Shortly thereafter the patient is given an inert

substance which she believes is a painkiller. Af-

ter the patient receives the inert substance, her

pain is most likely to

(A) increase

(B)

decrease

(C)

be unchanged

(D) respond to lower doses of opiates than pre-

viously

(E)



fail to respond to opiates in the future

Which of the following neuropeptides is most

closely implicated in the psychopathology of

pain?

(A)

Cholecystokinin

(B)

Vasopressin

(C)



Substance P

(D)

Somatostatin

(E)

Vasoactive intestinal peptide

3 6

Review Test

Directions: Each of the numbered items or incomplete statements in this section is followed by

answers or by completions of the statement. Select the one lettered answer or completion that

is best in each case.

A 65-year-old female patient has had a

stroke affecting the left hemisphere of her

brain. Which of the following functions is most

likely to be affected by the stroke?

(A)

Perception

(B)



Musical ability

(C)



Spatial relations

(D)

Language

(E)



Artistic ability

Which of the following structures connects

the two cerebral hemispheres?

(A)



The basal ganglia

(B)

The anterior

commissure

(C)



The reticular system

(D)

The hippocampus

(E)

The amygdala

A 23-year-old patient shows side effects

such as sedation, increased appetite, and

weight gain while being treated with antipsy-

chotic medication. Of the following, the mech-

anism most closely associatea with these ef-

fects is

(A)

blockade of serotonin receptors

(B)

blockade of dopamine receptors

(C)

blockade of norepinephrine receptors

(D) blockade of histamine receptors

(E)



decreased availability of serotonin

The autopsy of a 65-year-old man shows de-

generation of cholinergic neurons in the hip-

pocampus. In life, this man is most likely to

have suffered from

(A)

mania

(B)

depression

(C)



dementia of the Alzheimer type

(D)

anxiety

(E)

schizophrenia

The major neurotransmitter implicated in

dementia of the Alzheimer type is

(

A) serotonin

(B)

norepinephrine

(C)

dopamine

(D)

y-aminobutyric acid (GABA)

(E)



acetylcholine (ACh)

Chapter 4

10.

The major neurotransmitter involved in

the action of fluoxetine [Prozac] is

(A)

serotonin

(B)

norepinephrine

(C)

dopamine

(D)

y-aminobutyric acid (GABA)

(E)



acetylcholine (ACh)

11.

The neurotransmitter

metabolized to

MHPG (3-methoxy-4-hydroxyphenylglycol) is

(A)

serotonin

(B)

norepinephrine

(C)

dopamine

(D)

y-aminobutyric acid (GABA)

(E)



acetylcholine (ACh)

12.

The neurotransmitter metabolized to 5-

HIAA (5-hydroxyindoleacetic acid) is

13.

A 25-year-old male patient sustains a se-

rious head injury in an automobile accident.

He had been aggressive and assaultive, but af-

ter the accident he is placid and cooperative.

He also makes inappropriate suggestive com-

ments to the nurses and masturbates a great

deal. The area of the brain most likely to be af-

fected in this patient is the

14.

A 35-year-old female patient reports that

she has difficulty sleeping ever since she sus-

tained a concussion in a subway accident. The

area of the brain most likely to be affected in

this patient is the

(A)



right parietal lobe

(B)

basal ganglia

(C)

hippocampus

(D) reticular system

(E)

amygdala

(F)



left frontal lobe

Genetics, Anatomy, and Biochemistry

Behavior



15.

When he attempts to reproduce a clock

face drawn by the doctor, a 70-year-old man

who has had a stroke crowds all twelve num-

bers into the one o'clock to six o'clock position,

leaving the left side of the clock face blank.

The area of the brain most likely to be affected

in this patient is the

(A)



right parietal lobe

(B)



basal ganglia

(C)

hippocampus

(D) reticular system

(E)

amygdala

(F)



left frontal lobe

16.

An 80-year-old female patient has a

tremor, difficulty walking, and problems initi-

ating movement. The area of the brain most

likely to be affected in this patient is the

17.

A 69-year-old former bank president can-

not tell you the name of the current president

and has difficulty identifying the woman sit-

ting next to him (his wife). He began having

memory problems 3 years ago. The area of the

brain most likely to be affected in this patient

is the

18.

A 45-year-old male patient becomes de-

pressed following a head injury. The area of

the brain most likely to be affected in this pa-

tient is the

(A)



right parietal lobe

(B)



basal ganglia

(C)

hippocampus

(D) reticular system

(E)

amygdala

(F)



left frontal lobe

(A)

right parietal lobe

(A)

right parietal lobe

(B)

basal ganglia

(B)

basal ganglia

(C)

hippocampus

(C)

hippocampus

(D)

reticular system

(D)

reticular system

(E)

amygdala

(E)

amygdala

(F)

left frontal lobe

(F)

left frontal lobe

(A)

serotonin

(A)

right parietal lobe

(B)

norepinephrine

(B)

basal ganglia

(C)

dopamine

(C)

hippocampus

(D)

y-aminobutyric acid (GABA)

(D)

(E)

reticular system

amygdala

(E)

acetylcholine (ACh)

(F)

left frontal lobe

Answers and Explanations

TBQ-D.

Assaultive, impulsive, aggressive behavior like that seen in this 28-year-old male pa-

tient is associated with decreased levels of serotonin in the brain. Levels of 5-HIAA (5-hydroxy-

indoleacetic acid), the major metabolite of serotonin, have been shown to be decreased in the body

fluids of violent, aggressive, impulsive individuals as well as depressed individuals. MHPG

(3-methoxy-4-hydroxyphenylglycol), a metabolite of norepinephrine, is decreased in severe de-

pression while homovanillic acid (HVA), a metabolite of dopamine, is decreased in Parkinson's

disease and depression.

1-E. Increased body fluid level of homovanillic acid (HVA), a major metabolite of dopamine, is

seen in schizophrenia. Decreased HVA is seen in Parkinson's disease, depression and in med-

icated schizophrenic patients. Increased vanillylmandelic acid (VMA), a metabolite of norepi-

nephrine is seen in pheochromocytoma. Decreased body fluid level of 5-HIAA, a metabolite of

serotonin, is seen in depression and in bulimia (see also answer to TBQ).

2-B. y-Aminobutyric acid (GABA) is an inhibitory amino acid neurotransmitter in the CNS.

Thus, the activity of GABA in the brain of this anxious patient is likely to be decreased. Other

neurotransmitters are also involved in anxiety (see Table 4-2) There is no reason to believe that

GABA activity is higher than the activity of serotonin or norepinephrine in this patient.

3-C. After receiving naloxone, a chronic pain patient receives placebo medication (a dose of an

inert substance identified as a painkiller). Since the placebo response is based in part on activa-

tion of the endogenous opioid system, it will be blocked by naloxone, a substance which blocks

descending pain inhibitory pathways, and her pain will be unchanged. This experiment will not

necessarily affect her response to opiates in the future.

4-C. Substance P has been implicated in pain disorders. Cholecystokinin (CCK) is implicated in

schizophrenia and anxiety disorders, vasopressin, somatostatin, and vasoactive intestinal pep-

tide have been implicated in mood disorders. Somatostatin has been implicated also in Hunt-

ington's disease and dementia of the Alzheimer type.

5-D. Dominance for language in both right-handed and left-handed people is usually in the left

hemisphere of the brain. Perception, musical ability, artistic ability, and spatial relations are

functions of the right side of the brain.

6-B. The corpus callosum and the anterior and hippocampel

commissures

connect the two hemi-

spheres of the brain. The basal ganglia, reticular system,

hippocampes,

and amygdala do not

have this function.

7-D. Sedation, increased appetite, and weight gain are side effects of treatment with certain an-

tipsychotic agents. The mechanism most closely associated with these side effects is blockade of

histamine receptors since these antipsychotics are not specific for dopamine blockade. Blockade

of dopamine receptors by these antipsychotic medications is associated with side effects such as

parkinsonism-like symptoms and elevated prolactin levels.

8-C. Degeneration of cholinergic neurons in the brain is seen in dementia of the Alzheimer type,

movement disorders, and Down syndrome.

9-E. Acetylcholine (ACh) is the major neurotransmitter implicated in dementia of the Alzheimer

type.

10-A. Blockade of serotonin reuptake by presynaptic neurons is the primary action of the anti-

depressant fluoxetine.

11-B. Norepinephrine is metabolized to MHPG.

Chapter 4



Genetics, Anatomy, and Biochemistry of Behavior



12-A. Serotonin is metabolized to 5-HIAA.

13-E. The patient is suffering from Kldver-Bucy syndrome, which includes hypersexuality and

docility and is associated with damage to the amygdala.

14-D. Sleep-arousal mechanisms are affected by damage to the reticular system.

15-A. Damage to the right parietal lobe can result in impaired visual-spatial processing which

can lead to problems copying simple drawings and left side neglect.

16-B. This patient is showing signs of Parkinson's disease which is associated with abnormali-

ties of the basal ganglia.

17-C. This patient is probably suffering from dementia of the Alzheimer type. Of the listed brain

areas the major one implicated in dementia of the Alzheimer type is the hippocampus.

18-F. Of the listed brain areas, depression is most likely to be associated with damage to the left

frontal lobe.

Biological Assessment

of Patients with

Psychiatric Symptoms

A physician administers sodium lactate intravenously to a 28-year-old woman. Using this

technique, the physician is trying to provoke and thus identify

(A) conversion disorder

(B) amnestic disorder

(C)

malingering

(D) panic

disorder

(E)

major

depression

(See

"Answers

and

Explanations" at end of Chapter)

Overview

-Biological alterations and abnormalities can underlie psychiatric symptoms

and influence their occurrence. A variety of studies are used clinically to identify

such alterations and abnormalities in patients.

Il.

Measurement of Biogenic Amines and Psychotropic Drugs

A. Altered levels of Biogenic amines and their metabolites occur in some psy-

chiatric conditions (see Tables 4-2 and 4-3).

B. Plasma levels of some antipsychotic and antidepressant agents are mea-

sured to evaluate patient compliance or to determine whether thera-

peutic blood levels of the agent have been reached.

C. Laboratory tests are also used to monitor patients for complications of phar-

macotherapy.

Patients taking the antimanic agent carbamazepine [Tegretol] or the an-

tipsychotic agent clozapine [Clozaril] must be observed for blood abnor-

malities such as agranulocytosis.

Liver function tests are used in patients being treated with carba-

mazepine and valproic acid (an antimanic agent).



Behauioral Science

Thyroid function tests and renal panel should be used in patients who are

being treated with the antimanic agent lithium.

Patients taking lithium can develop hypothyroidism and, occasion-

ally, hyperthyroidism.

b. Lithium levels also should be monitored regularly because of the

drug's narrow therapeutic range.

III.

Dexamethasone Suppression Test (DST)

A. In a normal patient with a normal hypothalamic-adrenal-pituitary axis, dexa-

methasone, a synthetic glucocorticoid, suppresses the secretion of corti-

sol. In contrast, approximately one half of patients with major depressive

disorder have a positive DST (i.e., this suppression is limited or ab-

sent).

B. There is some evidence that patients with a positive DST (indicating re-

duced suppression of cortisol) will respond well to treatment with antide-

pressant agents or to electroconvulsive therapy (see Chapter 16).

C. The DST has limited clinical usefulness. Positive findings are not specific;

nonsuppression is seen in conditions other than major depressive disorder.

These disorders include: schizophrenia, dementia, pregnancy, anorexia

nervosa, or severe weight loss and endocrine disorders. Nonsuppression is

also seen with use, abuse, and withdrawal of alcohol and antianxiety agents.

IV Tests of Endocrine Function

A. Thyroid function tests are used to screen for hypothyroidism and hy-

perthyroidism, which can mimic depression and anxiety, respectively.

B. Patients with depression may have other endocrine irregularities such

as reduced response to a challenge with thyrotropin-releasing hormone, and

abnormalities in growth hormone, melatonin, and gonadotropin.

C. Reduced levels of gonadotropins are seen also in schizophrenia.

D. Psychiatric symptoms are associated with endocrine disorders such as Ad-

dison's disease and Cushing's disease.

V Neuroimaging and Electroencephalogram (EEG) Studies

-Structural brain abnormalities and EEG changes may correspond to specific

psychiatric disorders (Table 5-1).

VI.

Neuropsychological Tests

A. Neuropsychological tests are designed to assess general intelligence, mem-

ory, reasoning, orientation, perceptuomotor performance, language function,

attention, and concentration in patients with suspected neurologic problems,

such as dementia and brain damage.

B. Specific neuropsychological tests are described in Table 5-2.

VII. Other Tests

A. Amobarbital sodium [Amytal] interview

1. Intravenous (IV) administration of amobarbital sodium ("the Amytal in-

terview") may be useful in determining whether organic pathology is re-

Chapter 5

Table 5-1. Neuroimaging and Electroencephalography in the Biological Evaluation of the

Psychiatric Patient

Specific test or measure

Table 5-2. Neuropsychological Diagnostic Tests Used in Psychiatry

Test



Uses and Characteristics

Halstead-Reitan battery

Luria-Nebraska neuro-

psychological battery

Bender Visual Motor

Gestalt 'lest

Biological Assessment of Patients with Psychiatric Symptoms



Uses and Characteristics

•

Used to detect and localize brain lesions and determine their

effects.

•

Used to determine left or right cerebral dominance

•

Used to identify specific types of brain dysfunction, such as

dyslexia

•

Used to evaluate visual and motor ability through the

reproduction of designs

sponsible for symptomatology in patients who exhibit malingering, dis-

sociative disorder, or conversion disorder (see Chapter 14).

Amobarbital sodium can relax patients with these disorders or other

disorders involving high levels of anxiety and mute psychotic states

(see Chapter 11), so that they can express themselves coherently during

an interview.

B. Sodium lactate administration. IV administration of sodium lactate can

provoke a panic attack (see Chapter 13) in susceptible patients and

can thus help to identify individuals with panic disorder. Inhalation of car-

bon dioxide can produce the same effect.

C. Galvanic skin response ("lie detector" test)

The electric resistance of skin (galvanic skin response) varies with the

patient's psychological state.

Higher sweat gland activity, seen with sympathetic nervous system

arousal (e.g., when lying), results in decreased skin resistance.

Computed

•

Identifies anatomically based brain changes (e.g., enlarged

tomography (CT)

brain ventricles) in cognitive disorders such as dementia

of the Alzheimer type as well as in schizophrenia

Nuclear magnetic

•

Identifies demyelinating disease (e.g., multiple sclerosis).

resonance imaging

•

Shows the biochemical condition of neural tissues as well as

(

NMRI)

the anatomy without exposing the patient to ionizing radiation

Positron emission tomo-

•

Localizes areas of the brain that are physiologically

graphy (PET) or

active during specific tasks by characterizing and

functional MRI (fMRI)

measuring metabolism of glucose in neural tissue

Electroencephalogram

•

Measures electrical activity in the cortex

(EEG)

•

Is useful in diagnosing epilepsy and in differentiating delirium

(abnormal EEG) from dementia (often normal EEG)

•

Shows, in schizophrenic patients, decreased alpha waves,

increased theta and delta waves, and epileptiform activity

Evoked EEG (evoked

•

Measures electrical activity in the cortex in response to

potentials)

tactile, auditory, sound, or visual stimulation

•

Is used to evaluate vision and hearing loss in infants and brain

responses in comatose and suspected brain dead patients

Directions: Each of the numbered items or incomplete statements in this section is followed by

answers or by completions of the statement. Select the one lettered answer or completion that

is best in each case.

A 40-year-old woman reports that she has

no appetite, sleeps poorly, and has lost interest

in her normal activities. Which of the following

is the most likely laboratory finding in this

woman?

(A)

Positive dexamethasone suppression test

(DST)

(B)

Normal growth hormone regulation

(C)

Increased response to a challenge with

thyrotropin-releasing hormone

(D)

Normal melatonin levels

(E)

Hyperthyroidism

A 34-year-old female patient develops

agranulocytosis. This patient is most likely to

be taking which of the following agents?

(A)

Amobarbital sodium

(B)

Clozapine

(C)

Lithium

(D)

Dexamethasone

(E)



Sodium lactate

A 37-year-old male patient who has had a

stroke cannot copy a design drawn by the ex-

aminer. The test that the examiner is most

likely to be using to evaluate this patient is the

To determine which brain area is physiolog-

ically active when a 44-year-old male patient is

translating a paragraph from Spanish to En-

glish, the most appropriate diagnostic tech-

nique is

(A)

positron emission tomography (PET)

(B)

computed tomography (CT)

(C)

amobarbital sodium [Amytal] interview

(D) electroencephalogram (EEG)

(E)

evoked EEG

Review Test

To determine whether a 3-month-old infant

is able to hear sounds, the most appropriate di-

agnostic technique is

(A)

positron emission tomography (PET)

(B) computed tomography (CT)

(C)

amobarbital sodium [Amytal] interview

(D) electroencephalogram (EEG)

(E)

evoked EEG

A27-year-old female patient shows a sudden

loss of sensory function below the waist which

cannot be medically explained. To determine

whether psychological factors are responsible,

the most appropriate diagnostic technique is

(A)

positron emission tomography (PET)

(B)

computed tomography (CT)

(C)

amobarbital sodium [Amytal] interview

(D) electroencephalogram (EEG)

(E)

evoked EEG

To identify anatomical changes in the brain

of an 80-year-old female patient with dementia

of the Alzheimer type, the most appropriate di-

agnostic technique is

(A)

positron emission tomography (PET)

(B)

computed tomography (CT)

(

A) positron emission tomography (PET)

(B)

computed tomography (CT)

(C)

amobarbital sodium [Amytal] interview

(D)

electroencephalogram (EEG)

(E)

evoked EEG

(

Bender Visual Motor Gestalt Test

(C)

amobarbital sodium [Amytal] interview

(B)

Luria-Nebraska neuropsychological bat-

(D) electroencephalogram (EEG)

tery

(E)

evoked EEG

(C)

Halstead-Reitan battery

(D)

dexamethasone suppression test

To differentiate delirium from dementia in a

(E)

electroencephalogram (EEG)

75-year-old male patient, the most appropriate

diagnostic technique is

Answers and Explanations

TBQ-D. Intravenous administration of sodium lactate can help identify individuals with panic

disorder since it can provoke a panic attack in such patients. Amobarbital sodium interviews may

be useful in determining whether organic pathology is responsible for symptomatology in pa-

tients who exhibit malingering, amnestic, or conversion disorder (see Chapter 14). The dexa-

methasone suppression test can help in identifying major depression.

1-A. Poor appetite, poor sleep, and lack of interest in normal activities characterize patients suf-

fering from major depression (see Chapter 12). In this depressed woman, the dexamethasone

suppression test is likely to be positive. A positive result is seen when the synthetic glucocorti-

coid dexamethasone fails to suppress the secretion of cortisol as it would in a normal patient.

Also, in depression there may be abnormal growth hormone regulation and melatonin levels and

reduced response to a challenge with thyrotropin-releasing hormone. Hypothyroidism not un-

commonly results in depression; hyperthyroidism is more commonl;'

associated with the symp-

toms of anxiety.

2-B. Agranulocytosis (a disorder of the blood) is seen particularly in patients taking clozapine,

an antipsychotic, or carbamazepine, an anticonvulsant which is used to treat bipolar disorder

(see Chapter 12). Lithium, amobarbital sodium, dexamethasone, and sodium lactate are not

specifically associated with agranulocytosis.

3-A. The Bender Visual Motor Gest.- It Test is used to evaluate visual and motor ability by re-

production of designs. The Luria-Nebraska neuropsychological battery is used to determine cere-

bral dominance and to identify specific types of brain dysfunction, while the Halstead-Reitan bat-

tery is used to detect and localize brain lesions and determine their effects. The dexamethasone

suppression test is used to predict which depressed patients will respond well to treatment with

antidepressant agents or to electroconvulsive therapy. The electroencephalogram (EEG), which

measures electrical activity in the cortex, is useful in diagnosing epilepsy and in differentiating

delirium from dementia.

4-A. Positron emission tomography (PET) localizes physiologically active brain areas by mea-

suring glucose metabolism. Thus, this test can be used to determine which brain area is being

used during a specific task (e.g., translating a passage written in Spanish).

5-E. The auditory evoked EEG can be used to assess whether this child can hear. Evoked EEGs

measure electrical activity in the cortex in response to sensory stimulation.

6-C. The sodium amobarbital (Amytal) interview is used to determine whether psychological fac-

tors are responsible for symptoms in this patient who shows a non-medically explained loss of

sensory function (conversion disorder-see Chapter 14).

7-B. Computed tomography (CT) identifies organically based brain changes such as enlarged

ventricles. Thus, although not diagnostic, this test can be used to identify anatomical changes in

the brain such as enlarged ventricles of a patient with suspected dementia of the Alzheimer type.

8-D. Electroencephalogram (EEG) measures electrical activity in the cortex and can be useful

in differentiating delirium (abnormal EEG) from dementia (usually normal EEG).

Psychoanalytic Theory

A doctor becomes very

angry

with a patient when the patient does not take his medication.

The patient reminds the doctor o£ her rebellious son. This doctor's intense reaction to the

patient's behavior is most likely to be



result of

(A)

positive transference

(B)

negative transference

(D) dislike of the patient

(E) anger at the patient

(See "Answers and Explanations" at end of Chapter)

Overview

-Psychoanalytic theory is based on Freud's concept that behavior is determined

by forces derived from unconscious mental processes. Psychoanalysis and

related therapies are psychotherapeutic treatments based on this concept (see

Chapter 17).

II.

Freud's Theories of the Mind

--To explain his ideas, Freud developed, early in his career, the topographic the-

ory of the mind and, later in his career, the structural theory.

A. Topographic theory of the mind. In the topographic theory, the mind

contains three levels: the unconscious, preconscious, and conscious.

The unconscious mind contains repressed thoughts and feelings which

are not available to the conscious mind, and uses primary process think-

ing.

Primary process is a type of thinking associated with primitive

drives, wish fulfillment, and pleasure seeking and has no logic or con-

cept of time. Primary process thinking is seen in young children and

psychotic adults.

Dreams represent gratification of unconscious instinctive impulses

and wish fulfillment.



Behavioral Science

The preconscious mind contains memories that, while not immedi-

ately available, can be accessed easily.

The conscious mind contains thoughts that a person is currently aware

of. It operates in close conjunction with the preconscious mind but does

not have access to the unconscious mind. The conscious mind uses sec-

ondary process thinking (logical, mature, time-oriented) and can delay

gratification.

B. Structural theory of the mind. In the structural theory, the mind con-

tains three parts: the id, the ego, and the superego (Table 6-1).

II.

Defense Mechanisms

A. Definition. Defense mechanisms are unconscious mental techniques

used by the ego to keep conflicts out of the conscious mind, thus decreasing

anxiety and maintaining a person's sense of safety, equilibrium, and self-

esteem.

B. Specific defense mechanisms (Table 6-2)

Many defense mechanisms are immature (i.e., they are manifestations

of childlike or disturbed behavior).

Mature defense mechanisms (e.g., altruism, humor, sublimation, and

suppression) when used in moderation, directly help the patient or others.

Repression, pushing unacceptable emotions into the unconscious, is the

basic defense mechanism on which all others are based.

Table 6-1.

Freud's Structural Theory of the Mind

Structural



Topographic



Age at which

component level of operation it develops



Unconscious



Present at birth

Ego



Unconscious,



Begins to develop

preconscious

mmediately

and conscious



after birth

Superego



Unconscious,



Developed by

preconscious



about 6 years

and conscious



of age

Characteristics

•

Contains instinctive sexual and

aggressive drives

•

Controlled by primary process

thinking

•

Not influenced by external reality

Controls the expression of the id to

adapt to the requirements of the

external world primarily by the use

of defense mechanisms

Enables one to sustain satisfying

interpersonal relationships

Through reality testing (i.e.,

constantly evaluating what is valid

and then adapting that to reality),

enables one to maintain a sense

of reality about the body and the

external world

•

Associated with moral values and

conscience

•

Controls the expression of the id

Chapter 6

Table 6-2. Commonly Used Defense Mechanisms (listed alphabetically)

Defense

mechanism

Acting out

Identification

(Identification

with the Aggressor)

Intellectualization

Isolation of affect

Explanation

Avoiding personally unacceptable

emotions by behaving in an

attention-getting, often socially

inappropriate manner

Assisting others to avoid negative

personal feelings (a relatively

"mature" defense mechanism)

Not believing aspects of reality

that the person finds unbearable

Moving emotions from a personally

intolerable situation to one that

is personally tolerable

Mentally separating part of one's

consciousness from real life events

or mentally distancing oneself

from others

Unconsciously patterning

one's behavior after that of

someone more powerful (can

be either positive or negative)

•

Using the mind's higher functions

to avoid experiencing emotion

Failing to experience the feelings

associated with a stressful life

event, although logically

understanding the significance

of the event

Attributing one's own personally

unacceptable feelings to others

Associated with paranoid

symptoms and prejudice

Distorting one's perception of an

event so that its negative

outcome seems reasonable

Adopting opposite attitudes to

avoid personally unacceptable

emotions; i.e. unconscious hypocrisy

Psychoanalytic Theory



Example

A depressed 14-year-old girl

with no history of conduct

disorder has sexual encoun-

ters with multiple partners

after her parents divorce

A man with a poor self-

mage, who is a social

worker during the week,

donates every other

weekend to charity work

An alcoholic insists that he is

only a social drinker

A surgeon attending with

unacknowledged anger

toward his mother is

abrasive to the female

residents on his service

A teenager has no memory of

a car accident in which he

was driving and his

girlfriend was killed

Expressing personally uncomfortable

A man who is uncomfortable

feelings without causing emotional

discomfort (a relatively

"mature" defense mechanism)

about his erectile problems

makes jokes about Viagra

(Sildenafil)

A man who was terrorized by

his gym teacher as a child,

becomes a punitive, critical

gym teacher

A sailor whose boat is about

to sink calmly explains the

technical aspects of the

hull damage in great detail

to the other crew members

Without showing any emotion,

a woman tells her family

the results of tests which

indicate that her lung

cancer has metastasized

A man with unconscious

homosexual impulses

begins to believe that his

boss is homosexual

A man who loses an arm in

an accident says the loss of

his arm was good because

it kept him from getting in

trouble with the law

A woman who unconsciously is

resentful of the responsibil-

ities of child rearing, over-

continued

Altruism

•

Denial

•

Displacement

Dissociation

•

Humor

•

Projection

•

Rationalization

•

Reaction formation

•



Behavioral Science

Table 6-2. Commonly Used Defense Mechanisms (listed alphabetically)

Defense

mechanism

Regression

Splitting

Sublimation

Suppression

Undoing

Adapted from Fadem B, Simrey S:

High Yield Psychiatry.

Baltimore,

Williams

and Wilkins, 1998, p. 134.

Explanation

Transference Reactions

Reverting to behavior patterns like

those seen in someone of a

younger age

Categorizing people or situations

into categories of either "fabulous"

or "dreadful" because of

intolerance of uncertainty

Seen in patients with borderline

personality disorder

Expressing a personally

unacceptable feeling (e.g., rage)

in a socially acceptable way (a

relatively "mature" defense

mechanism)

•

Deliberately pushing personally

unacceptable emotions out of

conscious awareness (the only

defense mechanism that includes

some aspect of consciousness)

•

Believing that one can magically

reverse past events caused by

"incorrect" behavior by now

adopting "correct" behavior

Example

spends on expensive gifts

and clothing for her children

A 5-year-old child who was

previously toilet-trained

begins to wet the bed

when his mother has a new

baby

A patient tells the doctor that

while all of the doctors in

the group practice are

wonderful, all of the nurses

and office help are

unfriendly and curt

A man who got into fights as

a teenager, becomes a

professional prize fighter

A medical student taking a

review course for the

USMLE, mentally changes

the subject when her mind

wanders to the exam

during a lecture

A woman who is terminally

ill

with AIDS caused by

drug abuse, stops using

drugs and alcohol and

starts an exercise and

healthful diet program

A. Definition

-Transference and countertransference are unconscious mental atti-

tudes based on important past personal relationships. These phenomena

increase emotionality and may thus alter judgment and behavior in pa-

tients' relationships with their doctors (transference) and doctors' rela-

tionships with their patients (countertransference).

B. Transference

1. In positive transference, the patient has confidence in the doctor. If in-

tense, the patient may over-idealize the doctor or develop sexual feelings

toward the doctor.

2. In negative transference, the patient may become resentful or angry

toward the doctor if the patient's desires and expectations are not real-

ized. This may lead to noncompliance with medical advice.

C. In countertransference, feelings about a patient who reminds the doctor

of a close friend or relative can interfere with the doctor's medical judgment.

(A)

produce conflict in the conscious mind

(B)

are conscious mental techniques

(D)

are examples of the use of defense mecha-

nisms

(E)



decrease patients' sense of self-esteem

Which of the following structures of the

mind work on an unconscious level?

Which of the following structures of the mind

are developed in a normal 7-year-old child?

(A)



The id only

(B)



The id and the ego only

(C)



The id, ego, and superego

(D)

The ego and superego only

(E)



Neither the id, ego, nor superego

A 34-year-old woman relates that she wakes

up fully dressed at least twice a week but then

is tired all day. She also frequently receives

phone calls from men who say they met her in

a bar but whom she does not remember meet-

ing. The defense mechanism that this woman

is using is

(A)

denial

(B)

sublimation

(C)

dissociation

(D) regression

(E) intellectualization

A 35-year-old woman scheduled for surgery

the next day insists that her mother stay

overnight in the hospital with her. The defense

mechanism that this patient is using is

(A)

denial

(B) sublimation

(C)

dissociation

(D) regression

(E) intellectualization

Review Test

Directions:

Each of the numbered items or incomplete statements in this section is followed by

answers or by completions of the statement. Select the one lettered answer or completion that

is best in each case.

A primary care physician notices that many



Which of the following defense mechanisms

of her patients use statements like "I can't stop



is classified as the most mature?

smoking because I'll gain weight," or "when I'm

sick, I only want to eat junk food." Statements

like these

(A)

Denial

(B)

Sublimation

(C)

Dissociation

(D)

Regression

(E) Intellectualization

A patient whose father was often late for im-

portant family events storms out of the office

when told that the doctor will be late because

of an emergency. This patient's behavior is

most likely to be a result of

positive transference

negative transference

countertransference

dislike of the doctor

anger at the doctor

When having a manic episode, a 53-year-old

patient with bipolar disorder shows primary

process thinking. This type of thinking

(A)



is logical

(B)



is closely attuned to time

(C)



is associated with reality

(D) is accessible to the conscious mind

(E)



is associated with pleasure seeking

About 1 week after her final examination for

a biochemistry course, a medical student's

knowledge of the details of the Krebs cycle is

most likely to reside in her

(A)

unconscious mind

(B)

preconscious mind

(C)

conscious mind

(D) superego

(E)

ego

10.

A 15-year-old steals from family members

and friends. When no one is watching, he also

tortures the family cat. Which aspect of the

mind is deficient in this teenager?

(A)

The unconscious mind

(B)

The preconscious mind

(C)

The conscious mind

(D)

The superego

(E)



The ego

(A)

The id only

(B)

The id and the ego only

(C)

The id, ego, and superego

(D)

The ego and superego only

(E)

Neither the id, ego, nor superego



Behavioral Science

11.

A man who has unacknowledged anger to-

ward his wife kicks his dog. The defense mech-

anism that this man is using is

(A)

Regression

(B)



Acting out

(C)

Denial

(D)

Splitting

(E)

Projection

(F)

Dissociation

(

Reaction formation

(H) Intellectualization

(I)

Sublimation

(J)

Displacement

12.

A person who has unconscious violent feel-

ings becomes a surgeon. The defense mecha-

nism that this person is using is

(A)

Regression

(B)



Acting out

(C)

Denial

(D)

Splitting

(E)

Projection

(F)

Dissociation

(G)

Reaction formation

(H) Intellectualization

(I)

Sublimation

(J)

Displacement

13.

A husband who is unconsciously attracted

to another woman accuses his wife of cheat-

ing. The defense mechanism that this man is

using is

(A)

Regression

(B)



Acting out

(C)

Denial

(

D) Splitting

(E)

Projection

(F)

Dissociation

(G)

Reaction formation

(H) Intellectualization

(I)

Sublimation

(J)

Displacement

14.

A man who is unconsciously afraid of fly-

ing states his love of airplanes. The defense

mechanism that this man is using is

((A)

Regression

(B)

Acting out

(C)

Denial

(D)

Splitting

(E)

Projection

(F)

Dissociation

(G)

Reaction formation

(H) Intellectualization

(I)

Sublimation

(J)

Displacement

Answers and Explanations

TBQ-C. The doctor who becomes very angry at her patient for not taking his medication is show-

ing a countertransference reaction. This excessive show of emotion is a result of reexperiencing

feelings about her son's behavior in her relationship with the noncompliant patient. It is impor-

tant for the doctor to identify this reaction because it can interfere with her medical judgement.

In positive transference patients have a high level of confidence in the doctor. Patients may also

over-idealize or develop sexual feelings toward the doctor. In negative transference, patients be-

come resentful or angry toward the doctor if their desires and expectations are not realized. This

may lead to noncompliance with medical advice. This doctor's reaction to the patient is unlikely

to be related to dislike or fear of the patient.

1-D. Statements like "I can't stop smoking because I'll gain weight," or "when I'm sick, I only

want to eat junk food" are examples of the defense mechanisms of rationalization and regression,

respectively. In rationalization, a person distorts her perception of an event so that its negative

outcome seems reasonable, (i.e., because she feels unable to stop smoking), this patient claims

(and so she reasonably feels) that gaining weight is worse than smoking, a life-threatening habit.

In regression, ill patients revert to behavior patterns like those seen in someone of a younger age,

(i.e., eating junk food). Defense mechanisms such as these are unconscious mental techniques

which decrease anxiety and help people to maintain a sense of equilibrium and self-esteem.

2-C. In Freud's structural theory, the mind is divided into the id, ego, and superego. The id op-

erates completely on an unconscious level while the ego, and superego operate partly on an un-

conscious and partly on preconscious and conscious levels.

3-C. The id is present at birth, the ego begins to develop immediately after birth, and the super-

ego is developed by about age 6 years.

Chapter 6



Psychoanalytic Theory



4-C. This patient who relates that she wakes up fully dressed at least twice a week and receives

phone calls from men whom she does not remember meeting is exhibiting dissociatioe identity dis-

order (multiple personality disorder). Dissociation, separating part of one's consciousness from

real life events, is the defense mechanism used by individuals with this disorder. It is likely that

this patient met the men who have her phone number but does not remember meeting them be-

cause at that time she was showing another personality (see also Chapter 14).

5-D. Regression, going back to a less mature way of behaving, is the defense mechanism used

by this woman scheduled for surgery the next day who insists that her mother stay overnight in

the hospital with her.

6-B. Sublimation, expressing an unacceptable emotion in a socially acceptable way, is classified

as a mature defense mechanism. Denial, dissociation, regression, and intellectualization are all

classified as less mature defense mechanisms.

7-B. The patient who becomes very angry at his doctor for being late is showing a negative trans-

ference reaction. This excessive show of emotion is a result of reexperiencing feelings about his

father's lateness for important family events in his relationship with the doctor. In positive trans-

ference, a patient has confidence in and may idealize the doctor. In countertransference, a doc-

tor's feelings about a patient who reminds her of a close friend or relative can interfere with her

medical judgement. The patient's reaction to the doctor is unlikely to be related to dislike of or

the doctor.

8-E. Primary process thinking is associated with pleasure seeking, disregards logic and reality,

has no concept of time, and is not accessible to the conscious mind. Secondary process thinking

is logical and is associated with reality.

9-B.

Memory of the details of the Krebs cycle, while no longer in the forefront of the medical stu-

dent's mind, can be recalled relatively easily one week after the examination. This memory there-

fore resides in the preconscious mind. The unconscious mind contains repressed thoughts and

feelings, which are not available to the conscious mind. The conscious mind contains thoughts

that a person is currently aware of. See Explanation 10 (below) for definitions of the ego and

superego.

10-D. The superego is associated with moral values and conscience and controls impulses of the

id.

This teenager who steals from family members and friends and tortures the family cat is

showing deficiencies in his superego. Children and adolescents under age 18 years who have poor

superego development have conduct disorder (see Chapter 15). The id contains instinctive sex-

ual and aggressive drives and is not influenced by external reality. The ego also controls the ex-

pression of the id, sustains satisfying interpersonal relationships and, through reality testing,

maintains a sense of reality about the body and the external world.

11-J. In displacement, the man's personally unacceptable angry feelings toward his wife are

taken out on his dog.

12-1. In sublimation, the surgeon reroutes his unconscious, unacceptable wish for committing a

violent act to a socially acceptable route (cutting people during surgery).

13-E. Using projection, the husband attributes his unconscious, unacceptable sexual feelings to-

ward another woman to his wife.

14-G. In reaction formation, the man denies his unconscious fear of flying and embraces the op-

posite idea by stating that he loves airplanes.

Learning Theory

Typical Board Question

A 52-year-old woman has undergone three sessions of chemotherapy

in a

hospital. Before

the fourth session,

she

becomes nauseous when

she

enters the hospital lobby.

This

patient's

reaction is

a result

of the type of learning

best

described as

(A) operant conditioning

(B) classical conditioning

(C)

modeling

(

shaping

(E)

biofeedback

(

Answer in "Answers and Explanations" at

end

of Chapter)

Overview

A. Learning is the acquisition of new behavior patterns.

B. Methods of learning include classical conditioning and operant condi-

tioning.

C. Classical and operant conditioning are the basis of behavioral treatment

techniques, such as systematic desensitization, aversive conditioning, flood-

ing, biofeedback, token economy, and cognitive therapy (see Chapter 16).

II. Classical Conditioning

A. Principles. In classical conditioning, a natural, or reflexive response

(behavior) is elicited by a learned stimulus (a cue from an internal or ex-

ternal event).

B. Elements of classical conditioning

An unconditioned stimulus is something that automatically, without

having to be learned, produces a response (e.g., the odor of food).

An unconditioned response is a natural, reflexive behavior that does

not have to be learned (e.g., salivation in response to the odor of food).



Behavioral Science

A conditioned stimulus is something that produces a response follow-

ing learning (e.g., the sound of the lunch bell).

A conditioned response is a behavior that is learned by an association

that is made between a conditioned stimulus and the an unconditioned

stimulus (e.g., salivation in response to the lunch bell).

C. Response acquisition, extinction, and stimulus generalization

l. In acquisition, the conditioned response (e.g., salivation in response to

the lunch bell) is learned.

2. In extinction, the conditioned response decreases if the conditioned

stimulus (e.g., the sound of the lunch bell) is never again paired with the

unconditioned stimulus (e.g., the odor of food).

3. In stimulus generalization, a new stimulus (e.g., a fire bell) that re-

sembles a conditioned stimulus (e.g., the lunch bell) causes a conditioned

response (e.g., salivation).

D. Aversive conditioning. An unwanted behavior (e.g., setting fires) is

paired with a painful, or aversive, stimulus (e.g., a painful electric shock).

An association is created between the unwanted behavior (fire-setting) and

the aversive stimulus (pain) and the fire-setting ceases.

E. Learned helplessness

An animal receives a series of painful electric shocks from which it is un-

able to escape.

By classical conditioning, the animal learns that there is an association

between an aversive stimulus (e.g., painful electric shock) and the in-

ability to escape.

Subsequently, the animal makes no attempt to escape when shocked or

when faced with any new aversive stimulus; instead the animal becomes

hopeless and apathetic.

Learned helplessness in animals may be a model system for depression

(often characterized by hopelessness and apathy) in humans.

F. Imprinting is the tendency of organisms to make an association with and

then follow the first thing they see after birth or hatching (in birds).

III.

Operant Conditioning

A. Principles

Behavior is determined by its consequences for the individual. The con-

sequence, or reinforcement, occurs immediately following a behavior.

2. In operant conditioning, a behavior that is not part of the individual's

natural repertoire can be learned through reward or punishment.

B. Features

The likelihood that a behavior will occur is increased by reinforce-

ment and decreased by punishment. (Table 7-1)

Types of reinforcement include:

Chapter 7

Table 7-1. Features of Operant Conditioning

Example: A mother would like her 8-year-old son to stop hitting his 6-year-old brother. She can

achieve this goal by using one

the following features

operant conditioning

Extinction

C. Shaping and modeling

Behavior is elim- Child stops his hitting

inated by non-



behavior when the

reinforcement



behavior is ignored

by his mother

Learning Theory



Comments

Reward or reinforcement

(praise) increases desired

behavior (kindness

toward brother)

A reward can be praise or

attention as well as a

tangible reward

like money

•

Active avoidance of an

aversive stimulus (being

scolded) increases desired

behavior (kindness

toward brother)

•

Delivery of an oversive

stimulus (scolding)

decreases unwanted

behavior (hitting brother)

rapidly but not permanently

Extinction is more effective

than punishment for

long-term reduction in

unwanted behavior

There may be an initial

increase in hitting behavior

before it disappears

(1)

Positive reinforcement (reward) is the introduction

a posi-

tive stimulus that results in an increase in the rate

behavior.

(2)

Negative reinforcement (escape) is the removal

an aversive

stimulus that also results in an increase in the rate

behavior.

Punishment is the introduction

an aversive stimulus aimed at re-

ducing the rate

an unwanted behavior.

Extinction in operant conditioning is the gradual disappearance

learned behavior when reinforcement (reward) is withheld.

The pattern, or schedule,

reinforcement affects how quickly a

behavior is learned and how quickly a behavior becomes extinguished

when it is not rewarded (Table 7-2).

Resistance to extinction is the force which prevents the behavior

from disappearing when a reward is withheld.

Shaping involves rewarding closer and closer approximations

the

wanted behavior until the correct behavior is achieved (e.g., a child lear-

ing to write).

Modeling is a type

observational learning (e.g., an individual behaves

in a manner similar to that

someone she admires).

Feature

Effect on

Behavior

Example

Positive

Behavior is

Child increases his

reinforcement increased kind behavior

by reward

toward his younger

brother to get

praise from his

mother

Negative Behavior is

Child increases his

reinforcement increased by

kind behavior

avoidance or

toward his younger

escape

brother to avoid

being scolded

Punishment

Behavior is

Child decreases his

decreased by

hitting behavior

suppression

after his mother

scolds him

ment

Example

A teenager receives a

candy bar each time

she puts a dollar

into a vending

machine. One time

she puts a dollar in

and nothing comes

out. She never buys

candy from the

machine again.

A man is paid

$10 for every five

hats he makes.

He makes as many

hats as he can

during his shift.

A student has an

anatomy quiz every

Friday. He studies

for ten minutes on

Wednesday nights,

and for 2 hours on

Thursday nights.

After a slot machine

pays off $5 for a

single quarter, a

woman plays $50 in

quarters despite the

fact that she receives

no further payoffs.

After 5 minutes of

fishing in a lake

a man catches a

large fish. He then

spends 4 hours

waiting for

another bite.

Effect on behavior

Behavior (putting in a dollar

to receive candy) is rapidly

learned but disappears

rapidly (has low resistance

to extinction) when not

reinforced (no candy

comes out).

•

Fast response rate (many

hats are made quickly)

•

The response rate (studying)

increases toward end of each

the interval (week).

•

When graphed, the response

rate forms a scalloped

curve.

•

The behavior (playing the slot

machine) continues (is

highly resistant to

extinction) despite

the fact that it is only

reinforced (winning

money) after a large but

variable number of responses

•

The behavior (fishing)

continues (is highly

resistant to extinction)

despite the fact that

it is only reinforced

(a fish is caught) after varying

certain time intervals

Behavioral Science

Table 7-2. Schedules of Reinforc

Schedule

Reinforcement

Continuous

Presented after

every response

Fixed ratio

Presented after

a designated

number of

responses

Fixed interval

Presented after

a designated

amount of

time

Variable ratio

Presented after

a random and

unpredictable

number of

responses

Variable

Presented after

interval a random and

unpredictable

amount of

time