Behavioural Science

Defense mechanisims

Tools of the EGO to manage INTERNAL CONFLICT btw the ID and Super-ego
All unconscious : EXCEPT SUPPRESSION

Projection: your feelings onto someone else ( causes paranoia)

Denial: act as if never happened ( first response to bad news, substance abusers)
Splitting: EITHER GOOD OR BAD ( Borderline personality disorder, prejudice)
Blocking: temporary block in thinking
Regression: go to more childish state ( new sibling born, starts peeing again and
wants to be breast fed when werent before )
Somatization: psychological converted to bodily symptoms
Identification/ introjection: take the actions of others and do to self ( teenager act
like their fav rockstar) ( I will never act like my mother but they do)
Displacement : putting emotion on a more appropriate target
Repression: idea eliminated from CONSIOUSNESS (forget and dont remember it
ever) UNCOSIOUSLY ( forget and not retrievable)
Isolation of affect: dont display any emotion
Intellectualization: use intelligent words to remove emotions/ affect
Acting-out: act out strongly to cover up an emotion
Rationalization: look for a reason to justify action
Reaction Formation: unacceptable made into OPPOSITE
Undoing: acting out to reverse unacceptable behavior (man cheats, buy wife
flowers)
Passive-Aggressive: Hostility
Dissociation: separate self form experience ( extreme is dissociation disorder)
Humor: laughter covers pain
Sublimation: Unacceptable to SOCIALLY ACCEPTABLE ( man attracted to woman
becomes her mentor)
Suppression: CONSIOUS removal thought ( forget and retrievable)

Psychology random
IQ: mental age/ chronological age X 100 ( if equal then 100 is avg )
-SD is 15
- below two SD is retardation
Less 70: mental retardation
Mild
70-50 (20)

Self-supporting, with some guidance

Moderate
Severe
Profound

49-35 (14)
34-20 (14)
<20

Sheltered workshops, needs supervision (grade2)

Basic self care habits ( comb hair, pee, poo)

Variable RATIO is the slowest to extinguish slot machine

Mental status changes what is lost first : time> place> person
-Most common dementia Alzheimers (stroke 2nd)
- can be disoriented with
1. Alcohol/ drugs
2. Electrolyte/ fluid imbalance
3. Head trauma
4. HYPOglycemia
5. Nutritional deficiencies
Greif : normal is up to 2 months
- if more than 2 months pathological
- Pathological also if excessively intense, absent or inhibited grief,
delusion hallucinations
Child Abuse
1. Physical : usually mother / primary caregiver
Osteogenesis imperfect is BLUE SCLERA (they might throw u off
with iris
Retinal hemorrhage they will show a picture
Subdural hematoma, multiple buise, cigarette burns
2. Sexual: usually male and known to victim, peak at 9-12
* child neglect also needs to be reported to child protective services
*Infant deprivation : long term deprivation of affection
- >6 months irreversible changes
-severe can cause death

ADHD
Lower frontal lobe volumes
Normal IQ just difficulty focusing
Treat with stimulants : Methylphenidate (increase NE and serotonin)
Autism
Majority IQ LESS THAN 70 (mental retard)
Social interaction not reciprocated ( no separation anxiety, dont make eye
contact, dont hold out arms to parents)
Stereotyped behavior ( small interest number)
Potential causes
* NOT ASSOCIATED WITH MMR
Failure apoptosis cortex
Prenatal/perinatal trauma and infection
* Aspergers ( NORMAL IQ and language )
Rett

 X linked ( only seen in girls!, males they die)

Normal develop till 4 and then regress
Stereotypes hand-wringing
Childhood Disintegrative disorder
Normal till 2 then regress (loss language, social skill, bladder/bowl control,
play motor skills)
More in boys
Tourettes
Correlated with ADHD and OCD so can have all three
Treat antipsychotics

Delirium and Dementia

Delirium: abnormal EEG

Consciousness varies

Dementia : normal EEG

NORMAL

Causes Dementia
1. Alzheimers
Order of loss : time, place, person
Chromosome 21 APP ( amyloid precursor protein)
Chromosome 1 ( prenesilin 2) and chromosome 14 (prenesilin 1)

 Chromosome 19 ( Apoprotein E)
Diffuse atrophy brain
Can be reduction in choline acetyl transferase
Die from infection (pneumonia)
HIPPOCAMPUS affected first
2. Vascular dementia (stroke)
3. HIV
HIV encephalitis and myelitis
Kills brain cells and prevents their regeneration
Most people with AIDS have HIV dementia
Survive 4 months after onset
HIV level in spinal cord good predictor
Often misdiagnosed as depression
4. Picks Disease ( have tau also but neurofibrillary balls not tangle)
Frontal and temporal lobes deteriorate
5. Lewy Body dementia ( FAST DEMENTIA , AND LEWY BODY IN CORTEX)
6. Parkinsons ( late onset dementia, and lewy body in substantia nigra)
7. Substance abuse ( neurotoxic
8. CJD (prions, protein that cause this)
9. Huntington Chorea
10. Wilsons
Defect in chromosome 13
Ceruloplasmin deficiency
Copper accumulate in tissues ( cant be bound or excreted )
11. Normal Pressure hydrocephalus
Differentiate Alzheimers vs stroke
HTN in Stroke
Fast onset in stroke
Stroke has other neurological signs that are lateralize ( EX sensory loss,
Alzhimers dont have lateralized signs)
Depression may present like dementia in elderly patients(PSEUDODEMENTIA)

Picks disease: temporal and frontal

Alzhiemers whole brain

Psychology diseases
Psychotic Disorders
Schizophrenia
Genetic predisposition ( if sibling or parent= 12 %, if both parents= 40%)
Subtypes
1. Paranoid * better prognosis
2. Catatonic : Increase or decrease activity
-Decrease: mute, rigid, echopraxia (repeat), automatic obedience
-Increase: violent, destructive, repetitious stereotyped behavior
3. Disorganized * worst prognosis
-disorganized speech, behavior, appearance, explosive laugh,
grimacing
4. Undifferentiatted: combo of many
5. Residual: has episode but on general exam look fine with no psychosis
Positive Symptoms : associated with Dopamine high (mesolimbic)
Negative symptoms : associated with muscarninic ( Ach)
Good prognosis :
-Paranoid
-Late onset
-FAST onset
- Positive sympotms better than negative
-no family history
-* mood disorders better ( so schizoaffective better)
* differences:
- Schizophrenic 2 weeks WITHOUT MOOD ( Schizoaffective)
-IF Mood + psychotic together : Bipolar with psychotic features
Delusional disorder:
Beliefs lasting >1
Fixed, non-bizarre ( woman thing shes a movie star)
Functioning other than this is normal

Mood disorders

Depression more in WOMEN

Bipolar MEN= WOMEN ( MOST INHERITED PSYCHIATRIC DISEASE)

Depression sleep
Increase REM sleep, and latency to it decrease ( get there faster)
Decrease slow wave sleep (stage 4 the refreshing sleep)
Post partum
1. Blues : NORMAL, follow up in two weeks
2. Depression: 2 week- 2 months
3. Psychosis : days to weeks ( delusion, homicidal/suicidal)
Bipolar
Need mood stabilizers: lithium, valproic acid (antiepileptic), carbamazepine
atypical antipsychotics
Hypomania doesnt cause disturbance in social or occupational functioning
Suicide risks
NUMBER ONE RISK : PERSON WHO HAS TRIED BEFORE
Men succeed more, women try more
-success both from gun #1, women attempt with pills and poision
Age : teens highest is natives, elderly (lowest is native)
Race: white most
Depression and alcohol number ones
Lack of support, medical illness, sexual assault history

Anxiety disorders

Obsessive compulsive disorder (EGO-DYSTONIC )

-Associated with tourettes
Obsessive compulsive personality ( EGO-Syntonic)
PTSD lasts more than a month
-can have long latency ( ex: abused child appear PTSD in adult)

Eating Disorders
Anorexia
BMI < 17.5
Restrictive and Purging types

purging can also throw up not

just bulimia
Electrolyte imbalances ( HYPOKALEMIA,

Bulimia
Normal or overweight a bit
Binge and then compensate
Purging, non-purging
* at least twice a week for 3 month
Electrolyte imbalance: hypokalemia and

leads to arrhythmias)
Lanugo : very fine bodily hair
Dental cavities

alkalosis ( from vomiting acid)

From throwing up
- Russells sign : calluses on dorsal hand
-Hypokalemia and alkalosis
-dental cavities
-parotid gland enlargement
-Mallory Weiss: longitudinal tears
esophagus and PAINFUL

Somatoform Disorders
Somatization: must have 4 pain, 2 GI, 1 sexual, 1 psuedoneuological
Conversion: stress to physical neurological la belle
Hypochondriasis: still think something wrong although results negative
Pain disorder: prolonged pain with no physical finding
Factitious/ Muchausen: know faking it but drive unconscious
Malingering: know faking and know drive

Sex
Gender Dysphoria: not happy with their sex at birth ( usually change it Transsexual)
-born male, wants to be female, attracted to males (heterosexual)

Substance
PCPAM
1. precontemplation: dont think they have a problem
2. Contemplation: know have a problem but havent done anything
3. Preparation: make a plan
4. Action: change
5. Maintenance: prevent things that can relapse you
6. Relapse
Substance dependence (BODY): Tolerance and withdrawal
Subtance abuse (LIFE EFFECT): affect school, work, fail fulfill obligation,
compulsive use (even if dangerous), legal issues
-All drugs work on dopamine mesolimbic reward pathway
-Injection cause
- Right side endocarditis
-Hepatitis, abscesses
-HIV, AIDS

-overdose
Alcohol
Wernike Korsakoff
Periventricular necrosis of mammillary bodies
Wernike: confusion, ataxia, opthalmolegia ( cerebellum anterior
destroyed)
Korsafoff: IRREVERSIBLE memory loss, confabulation, personality
(mammillary bodies)
Wallory Weiss: longitudinal and painful vs esophagueal varies (painless)
Treat : thiamine, sedative- hypnotics, lorazepam if seixure
Withdrawal
1. Day 1: autonomic hyperactivity
2. 2: seizure
3. 3: Delirium Tremens: psychotic and confusion ( LIFE THREATENING)
Fetal Alcohol Syndrome: #1 cause mental retardation ( then Downs and
Fragile X)

Conjunctiva injection: marijuana

Depressants
Opiods ( morphine, heroine, methadone, codein, oxycodone)
Overdose : seizure
Antedote : Naloxone/ naltrexone : opiod antagonist
Flu like withdrawal (unpleasant but not life threatening)
Treatment: Methadone LONG life (safe in pregnancy)
Barbituates : no ceiling ( can die with overdose + withdrawal)
-must treat withdrawal with barbiturate not benzo
Benzo: have ceiling effect (die with withdrawal)

-intoxication treat with FLUMAZENIL ( competitive GABA antagonist)

-Withdrawal treat with long acting benzo (diazepam)
Stimulants
Amphetamines( methamphetamine, crystal meth)
-euphoria, delusions, hallucinations
-Increase Dopamine, NE, and serotonin (prevent uptake)
Cocain ( crack cocain) :
-same as amphetamine
-MI, sudden cardiac death, stroke (intense vasoconstriction), angina
-withdrawal both meth and cocain is depression, fatigue, increased appetitie,
suicide
MDMA/ Ecstacy/ Molly (amphetamine + hallucinogen)
-High Serotonin
-Hyperthermia, social LOVE, convulsion, DEATH
-fatigue the day after
Caffiene: adenosine receptor antagonist, increase cAMP in neurons
Hallucinogens
PCP (angel dust) : VIOLENT , ataxia, VERTICAL NYSTAGMUS + horizontal
-work on NMDA glutamate by blocking it
Ketamine similar with NMDA
LSD : increase serotonin
-visual hallucinations
-Flash back years later
Marijuana
-urine one month after use
*Inhalants look for crusting on the nose
Anabolic steroids have LOW POTASSIUM
Report physician to the person in charge of that level

Statistics

Accuracy: TP + TN / Total all

Capture max infected people : 100% sensitivity, aka HIGH NPV, aka, FN=0

The median always captures half of the patients, so can always get the number from
normal curve or skewed ones.

Alpha error: False true

Beta error: False negative
Power: True positive
- 1-beta
- increases with
1. INCREASE SAMPLE SIZE
2. INCREASE EFFECT SIZE

Highest clinical evidence is the META-ANALYSIS

Cross over study limits confounding variables
Reciever Operating Curve

Best is the Green (choose one with

Grestest area under the curve)
Choose one with 90 degree angle
This makes sensitivity highest
Good for screening

Prevalence
Sensitivity and specificity come with the test ( they dont chancge with
Prevalence)
Prevalence directly correlated with PPV increase together, NPV decrease
Prevalnce= incidence X duration ( but can have incidence increase without
prevalence increase if the those who die or recover the same)
Sensitivty = NPV related due to False Negative
Specificity = PPV due to False Positive
Accuracy : TP + TN/ Total
Weird biases names
Pygmalion: experimental expectancy prophecy
Hawthorne: if group knows they are studied they act different
Berkson: select patients only in the hospital
Variability
Range: highest lowest value
SD(s)
Variance (s^2)
Standard Eror Mean (SEM) indirectly to population: as population increase
the SEM decreases

Hospitals/ Health insurance

Deductible : pay a certain rate always

Copayment: if sick and get service they the patient pays some (less) and the
insurer more
Private Insurer
HMO Health Maintenance organization: prepaid group practice
Payment by capitation ( make money if patients not sick )
Members pay fixed price a month
Prefered Provider Organization PPO:
Fee for service at a dscount
Doctor makes money by NUMBERS (service discounted but more
patients)
Government Paid Programs
MediCARE : elderly > 65 and end stage renal disease
Part A: pay hospital
Part B : pay physicians
Part C : Medicare advantage ( through private companies include
benefits and can include PRESCRIPTION DRUGS)
PART D: prescription drugs
Still have deductibles and copay ( Medi CAID doesnt)
MedicAID : health care for those on welfare
Diagnostic related Groups
People put into groups based on age, condition, etc and there is a FIXED
amount the govt will pay for them ( if it costs more not their problem
since all patients in that group should get about the same treatments)
Negeatives
1. Earlier discharge form hospital ( so they dont lose money)
2. Upcoding: ILLEGAL to record a code that will pay more when u didnt do
it

Ethics
When informing a patient of difficult information, the most appropriate
course of action is to:
1) immediately inform the patient of the bad news you have cancer
2) give the patient a moment to think about and process the information
3) explain what the bad news means for the patient
4) answer any questions the patient may have
Capacity ( medical term) VS competence (legal term)

Competent unless
1. History suicide
2. Psychotic
3. Patient cannot communicate

Therapeutic Privilege: The physician chooses what to do to unconscious or

confused patient in order to protect their life
Locum Parentis: when parents cant be contacted and its an emergency doctor
takes control
Written consent can be revoked anytime ORALLY
If the treatment is pointless but family insists (MUST CONTINUE) VS brain dead
can stop even if they insist
Mentally ill patients retain their rights, if they currently dont have any odd
symptoms then they can choose medical things like refusing treatment
NEVER refuse patient treatment,
Participate in religious things with them if they ask you
If patients want inappropriate treatment they cant have it
Acknowledge and legitimize feelings

Life in U.S
Divorce

50% divorce
#1 reason for mental hospitalize
doctor occupation highest divorce
Well being index : lowest for separated highest for married
Most likely risk : kid of parents who divorced
-education of woman low

Social economic status : EDUCATION+ OCCUPATION

DOESNT INCLUDE INCOME!

EX: high income drug dealer, low SES
Priest low income , high SES
Hgh SES better health except ( ANXIETY, BREAST CANCER, BIPOLAR)
* think women over work ( breast cancer bc kids later)

Suicide

Teens its on the rise bc of BULLYING

-highest risk is male, depressed and alcohol use
-most have mental illness(therefore treat cause, not suicide symptom)
-Native American most
Elderly > 65
-native American least
Upper and middle class, white,
Depression + alcohol 15%, schizophrenia 10%, borderline personality 5%
Low serotonin is suicide (depression think)
NEVER ASSIST SUICIDE ON USMLE

Health

Heart disease #1 die

Diagnosis
-Essential hypertension MEN
-Pregnancy WOMEN
#1 malparactise suit : breast cancer
Hospitalization
-most admissions: mental illness
- most days : <3
- work related disability: muscular skeletal

HIV
With AIDs right now then were homo/ bisexual
With HIV right now IV drug abuse
Recent increase transmission male female especially if on period
Most dangerous sexual practice : ANAL SEX
Mom HIV + then 100% kids test positive since antibodies transfer this is why
dont do ELISA
-do PCR to see if infected
-RT-PCR to quantify amount virus
* prevent transmission by giving AZT + C-SECTION + DONT
BREAST FEED
Reportable diseases
Be A SSSMMART Chicken or your Gone with LYME
B: Hepitits B
A: heptatitis A

S: Syphilis
S:salmonella
S:Shigella
M: mumps
M: measles
A: AIDS
R: Rubella
T: T.B
Chicken pox
Gonorrhea + chlamydia
Lyme disease
Cancer: Women LUNG CANCER ON THE RISE
Infant mortality :
Highest African Americans
Native americans
Latin and white low ( except Puerto Ricans)

Sexuality
Avg age first sexual experience 16
50% done use regular birth control
hightest teenage pregnancy: Hispanic highest black Native white
asia
Highest incidence :HPV
Chlamydia number one, then gonorrhea in teens
Gender Identity stablished by 3 years old
Everyone from baby to elderly MASTERBATE , its normal
Paraphilic Disorders
Voyeurism : peeping tom
Frotteurism: rubbing onto people
Coprophilia : poop
Urophilia: urination
Necrophilia: dead people
Hypoxyphilia: hypoxia during orgasm

-Hypoactive (engage in sex but not too fond of it) vs Sexual aversion ( avoid all
sexual contact
-Females report peak sexual desire before period
-erection issues : postage stamp test, snap gauge ( have erection during REM ( high
ACH)
-Dyspareunia: reccurent persisitent pain before, during, after sex
-Vaginismus : involuntary muscle contraction so penis cant enter
-SEXUAL INTEREST DOESNT DECREASE WITH AGE!

Learning and Behavior Modification

Classical conditioning ( need something involuntary)
NEW stimulus elicits SAME automatic action
Stimulus generalization: ALL hospitals cause chemo patient to vomit
Extinction: removing the Unconditioned STIMULUS from conditioned
STIMULUS will cause it CS CR to fade
Operant/ Instrumental Conditioning ( action voluntary
Reinforcement increases the probability of doing an action

Reinforcement needs to be AFTER ACTION

Continuous reinforcement: faster learn, faster extinction

Variable reinforcement : learn slower, slower extinction

-Variable ratio: LEAST EXTINCTION slot machine
Spontaneous recovery: after extinction the response occurs randomly
Secondary reinforcement: token associated with real reinforcement
Therapy based on Operant
-Shaping: slowly move to desired action (autistic child)
- Stimulus control: remove stimulus that trigger behavior Ex:
drinking causes smoking
-biofeedback
-Extinction: discontinue reinforcement that is causing bad behavior
ex: time out for misbehaving
-Fading: gradually remove the reinforcement without them knowing

Behavioural therapy = classic conditioning

Systemic desensitization: present the phobia in steps from least to most

scared of but pair it with RELAXATION

Exposure: just expose to complete fear

Aversive conditioning: repel the person from

Behavioural models of Depression
1. Learned Helplessness : even tho there is help they dont take it
- all avoidance response is gone
- well nothing works why bother
- passive
2. Low rate of response- contigent reinforcement:
-TOO LITTLE POSITVE REINFORCEMENT
-may lack social skills to elicit positive reinforcement from peple

Special topics
Anxiety: need medium anxiety to have optimum in performance
Pain is subjective therefore we need to give drugs if they say they are in pain
-Time contingent in hospital
-Pain contingent in Hospice ( self control and self administer)

Psychological Health and testing

Holmes and Rahe rate stressful events ( the most stressful is DEATH SPOUSE)
-MORE STRESS= more unhealthy later
-widow have higher rate of <3 attack in a year after spouce dies
IQ is a good predcotr of academic excellence
IQ stable from 5 onwards
IQ tests: Wechsler
1. WAIS-R : adults
2. WISC: 6-17 (children)
3. WPPSI : 4-6 (preschool)
4. Stanford- Binet Scale: 2-18
Personality Test

-Objective
1. Criterion referenced: results compared with present standard
2. Norm referenced: referenced to normal
-MMPI : Minnesota Multiphasic personality inventory
True and False test to over 550 things
-Projective test : ambiguous stimumuli
1. Rorschach Inkblot
2. TAT thematic apperception test: tell a story whats going on in pic
3. Scentence completion
4. Projective drawing: patient given paper and asked to draw something
Neuropsychological Tests TWO NAME TEST
- IQ IS HERE

Sleep

cerebral cortex most affected by no sleep

Is sleep deprived next sleep will have MORE STAGE 4, LESS REM
REM LONGTERM MEMORY HIPPOCAMPUS
-latency in adults is 90 minutes
Hormonal
-growth hormone increase
-Prolactin increase bc dopamine decrease
-serotonin increase ( initiate sleep)
-TSH decrease cold at night
REM
NREM
Brain ON, memory dream
Brian off
Body off (but erection here high Ach)
Body on (sleep walking, jaw clench)
Increase as night goes on
Highest at first half night
Decrease if sleep deprived
Increase if sleep deprived
Increase with exercise
Decrease after 80
Vanish in eldery stages 3 and 4 therefore
dont feel rested
Neurotransmitters from initiate sleep to wake up SANDman
Serotonin: help initiate sleep
AcH: higher in REM
NE: lowers REM
Dopamine: produces arousal and wakefulness ( rises when waking)
-why Schizophrenics dont sleep much
Narcolepsy
Start with REM
Cataplexy pathognomonic
Have hallucinations before or after
DEFICIENCY HYPOCRETIN / OREXIN ( cant regulate sleep)

SIDS ( unexplained death in sleep of kids under 1)

IF PLACE ON BACK REDUCE RISK 50%
Higher risk of mothers who smoke
Night terror
In stage 4
Dont recall when woke up
Precursor to temporal lobe epilepsy

Nightmare
REM
Recall

Random
Incidence: NEW EVENTS / those at risk
Prevalence: ALL CASES( old + new) / total population at risk
If confidence interval doesnt have null then statistically significant, and then the p
value is LESS THAN 0.05
P value : less than 0.05 percent chance that the results obtained were due to chance
-also 0.05 percent that this is an alpha/ type 1 error
confounding variable is is exposure- disease relationship can be described by
another variable (confounder)
ARR= control- treatment
MODE IS MOST RESISTANT TO OUTLIERS
DIFF payment methods
Capitation: doctors paid a fixed amount PER PATIENT (not service). Causes high
preventative care
Fee for service: they are paid for every service therefore they dont care about
preventative medicine
Discounted fee for service
Salary : fixed salary therefore dont care about the services or number or people.

TESTS
Two sample z test and two sample t test used to compare TWO GROUP, MEANS
Chi- square test for CATEGORICAL DATA 2x2 table
ANOVA: MEANS of 2 or more groups
Meta analysis: pooling data from serveral studies to conduct an analysis having a
larger STATISTICAL POWER
Power: 1- beta error
- probability rejecting the null hypothesis when it is truly false
- probability finding true relationship
- depend on sample size. INCREASE SAMPLE SIZE INCREASE POWER
- TYPICALLY SET AT 80%
TYPE 1 error is like specificity but False positive numberator
Type 2 error like sensitivity
Berkson bias: selecting patients only hospitalized as the control group
Z score for 2 SD: 1.96
Z score for 2SD : 2.58