6 BehavCoursepack

Behavioral Medicine
Newborn Assessment
Neelam G. Gidwaney, M.D.
Birth Weight and APGAR Score

Birth Weight
Defined as LOW if < 2500g
Increased risk of infection and complication
Apgar score
Pediatrician assesses newborn
5 areas (each scored 0-2)
APGAR: appearance, pulse, grimace, activity, respiration
BEHAV01_01_
APGAR Scoring System

Evaluation
0 Points
1 Point
2 Points
Heart Rate
< 100/min
> 100/min
Respiration
None
Irregular, shallow gasps
Crying
Color
Blue
Pale, blue extremities
Pink
Tone
None
Weak, passive
Active
Reflex irritability None
Facial grimace
Active withdrawal
BEHAV01_01_
Behavioral Medicine
Developmental Milestones
Neelam Gidwaney, M.D.
Milestones
Infant (0 - 12 months old): reflexes
Sits, crawls, walks
Toddler (1 - 3 years old)
Climbs, stacks blocks, talks
Preschool (2.5 - 4 years old)
Toilet trained, rides tricycle, hops, simple drawings
BEHAV01_02_
Development Milestones
Age
Physical and Motor

Development
First
Year
of
Life
Puts everything in mouth

Sits with support (4 months)
Stands with help (8 months)
Crawls, fear of falling (9
months)
Pincer grasp (12 months)
Follows objects to midline (4
wk)
One-handed approach/grasp
of toy
Feet in mouth (5 months)
Bang and rattle stage
Changes hands with toy (6
months)
BEHAV01_02_
Social Development
Parental figure central
Issues of trust are key
Stranger anxiety (6
months)
Play is solitary and
exploratory
Pat-a-cake, peek-a-boo
(10 months)
Cognitive
Development
Language
Development
Sensation/movement
Schemas
Assimilation and
Accommodation
Laughs aloud (4
months)
Repetitive responding
(8 months)
mama, dada (10
months)
Development Milestones: Year 1

Age
Year 1
Physical and Motor

Development
Walks alone (13 months)
Climbs stairs alone (18
months)
Emergence of hand
preference (18 months)
Kicks ball, throws ball
Pats pictures in book
Stacks three cubes (18
months)
BEHAV01_02_
Social Development
Separation anxiety (12
months)
Dependency on
Parental figure
(rapprochement)
Onlooker play
Cognitive
Development
Language
Development
Achieves object
permanence
Great variation in
timing of language
development
Uses 10 words

Age
Year 2
Physical and Motor

Development
High activity level
Walks backward
Can turn doorknob, unscrew lid
jar
Scribbles with crayon
Able to aim to throw ball
Stands on tiptoes (30 mo)
Stacks six cubes (24 mo)
BEHAV01_02_
Social Development
Cognitive
Development
Language
Development
Selfish and selfcentered

Imitates mannerisms
and activities
May be aggressive
No is favorite word
Parallel play
A world of objects
Can use symbols
Transition objects
Strong
egocentrism
Concrete use of
objects
Use of pronouns
Parents
understand most
words
Telegraphic
sentences
Two-word
sentences
Uses 250 words
Identifies body
parts by pointing

Age
Year 3
Physical and Motor

Development
Rides tricycle
Stacks 9 cubes (36 mo)
Alternates feet going upstairs
Bowel and bladder control
(toilet training)
Draws recognizable figures
Catches ball with arms
Cuts paper with scissors
Unbuttons buttons
Can copy circle
BEHAV01_02_
Social Development
Fixed gender identity
Sex-specific play
Understands taking
turns
Knows sex and full
names
Cognitive
Development
Language
Development
Recognizes
common
objects in
pictures
Completes sentences
Uses 900 words &
Understands 4 that
many words
Strangers can
understand
Recognizes common
objects in pictures
Can answer: Which
block is bigger?

Age
Year 4
Physical and Motor

Development
Alternates feet going down
stairs
Hops on one foot
Grooms self (brushes teeth)
Counts fingers on hand
Can copy cross (4 years)
Can copy rectangle (4
years)
BEHAV01_02_
Social Development
Imitation of adult
roles
Curiosity about sex
(playing doctor)
Nightmares and
monster fears
Imaginary fears
Cognitive
Development
Language
Development
Points to and
counts three
objects
Repeats four
digits
Names colors
Can tell stories

Uses prepositions
Uses plurals
Compound
sentences

Age
Year 5
Physical and Motor

Development
Complete sphincter control
Brain at 75% of adult weight
Draws recognizable man with
head, body, and limbs
Dresses and undresses self
Catches ball with two hands
Can copy square
BEHAV01_02_
Social Development
Conformity to peers
important
Romantic feeling for
others
Oedipal phase
Cognitive
Development
Language
Development
Counts 10
objects correctly
Asks the meaning of

words
Abstract words
elusive
Development Milestones: Years 6 - 12

Age
Years
6-12
BEHAV01_02_
Physical and Motor

Development
Boys heavier than
girls
Refined motor skills
Rides bicycle
Gains athletic skill
Coordination
increases
Can copy triangle (6
years)
Can copy diamond
(7 years)
Social Development
Rules of the game
are key
Organized sports
possible
Being team member
focal for many
Separation of the
sexes
Demonstrating
competence is key
Cognitive
Development
Language
Development
Abstracts from objects

Law of conservation
achieved
Adherence to logic
No hypotheticals
Mnemonic strategies
Personal sense of
right and wrong
Shift from
egocentric to social
speech
Incomplete
sentences decline
Vocabulary expands
geometrically
(50,000 words by
age 12)
Development Milestones: Years 12

Age
Years
> 12
Physical and Motor

Development
Adolescent growth
spurt (girls before
boys)
Onset of sexual
maturity (10 y)
Development of
primary and
secondary sexual
characteristics
BEHAV01_02_ 10
Social Development
Identity is critical issue
Conformity most
important (11 to 12 y)
Organized sports
diminish for many
Cross-gender
relationships
Cognitive
Development
Language
Development
Abstracts from
abstractions
Systematic
problem-solving
strategies
Can handle
hypotheticals
Deals with past,
present, future
Adopts personal
speech patterns
Communication
becomes focus of
relationships
Behavioral Medicine
Tanner Stages of Development
Tanner Development
Tanner Stages of Development
Stage Female Breast
Female and Male Pubic Hair
Male Genitalia
Preadolescent
None
Childhood size
Breast Bud
Sparse, long straight
Enlargement of scrotum/testes
Areolar diameter
enlarges
Darker, curling, increased

amount
Penis grows in length; testes

continue to enlarge
Secondary mound;
separation of contours
Course, curly, adult type
Penis grows in length/breadth,

scrotum darkens, testes enlarge
Mature Female
Adult; extends to thighs
Adult shape/size
BEHAV01_03_
Behavioral Medicine
Sexual Dysfunction
Sexual Dysfunction
Common causes of sexual dysfunction
Drugs
Diseases
Psychological
BEHAV01_04_
Behavioral Medicine
Stress and BMI
Stress, BMI
Stress
Fatter (lipids, cholesterol, cortisol)
Decreased immune system
BMI
Weight over height squared
Know ranges of underweight, normal, overweight, obese,
morbidly obese
BEHAV01_05_
Behavioral Medicine
Changes in the Elderly
Elderly Development
Sexual changes
Men: longer refractory, slower erection
Women: vaginal dryness
Sleep
Decreased REM, slow-wave, increased wakening
Increased suicide rate
Decreased muscle mass, increased fat
Decreased organ function (hepatic and renal)
BEHAV02_01_
Behavioral Medicine
Drug Metabolism in the Elderly
Pharmacokinetic Changes in the Elderly: GI

Pharmacological
Consideration
Physiological Age-Related
Changes
Altered GI absorption
and/or function
A slowing of GI transit can
prolong the time until orally

administered drug onset, as well
as increase the effective
duration of these medications.
BEHAV02_02_
Additional Considerations /
Comments
Disorders that alter gastric
and/or intestinal pH may
decrease or increase the
absorption of some
medications.
Surgically altered
anatomy may reduce the
absorption of some
medications.
Pharmacokinetic Changes in the Elderly: Distribution

Pharmacological
Consideration
Distribution
BEHAV02_02_
Physiological Age-Related Changes

Increased fat mass
Increased fat: lean ratio may increase the
volume of distribution for fat soluble
drugs (i.e., psychotropics)
Decreased muscle mass
Use of IM injections may result in higher
than expected drug levels
Decreased total body water
Decreased water: lean ratio may
decrease the distribution of water soluble
drugs
Additional
Considerations /
Comments
Obesity may contribute
to the increased
volume of distribution
for fat soluble drugs.
Edematous states,
including heart failure,
may result in an
increased volume of
distribution for watersoluble drugs.
Pharmacokinetic Changes in the Elderly: Liver

Pharmacological
Consideration
Hepatic metabolism Overall drug-metabolism via

cytochrome system generally
decreases with increasing age
Phase I metabolism may decrease
with increasing age
Phase II metabolism is generally
less affected by increasing age
BEHAV02_02_
Comments
Consider any drug-drug
interactions that may affect
metabolism
Pharmacokinetic Changes in the Elderly:

Kidneys
Pharmacological
Consideration
Comments
Renal elimination
BEHAV02_02_
Glomerular filtration rate decreases

with increasing age, resulting in
decreased drug and drug metabolite
excretion
Decreased excretion of active or
toxic metabolites can result in
increased incidence of adverse
effects (i.e., meperidine)
Chronic kidney disease

may worsen the degree of
drug elimination via the
renal route
Drug metabolites and/or
water soluble agents may
have increased half-lives
Behavioral Medicine
Grief
Grief
Can last 2 months
Pathologic (treat it) if greater than 2 months, excessively strong, or
delayed/inhibited/or denied
Note: this criteria has changed in DSM V and if the patient meets the
criteria for major depressive disorder (MDD) they can be treated for
this condition
DSM V removed the bereavement exclusion for MDD
BEHAV02_03_
Kbler - Ross
Denial, anger, bargaining, depression,
acceptance
Not in order, can be overlapping
BEHAV02_03_
Grief Vs. Depression

Normal Grief
Depression
Normal up to 2 years
Can last longer than 1 year
Crying, decreased libido, weight loss, insomnia
Crying, decreased libido, weight loss, insomnia
Longing, wish to see loved one, may think they

hear/see loved one in crowd
Abnormal overidentification, personality change
Loss of other
Loss of self
Suicidal ideation rare
Suicidal ideation common
Self-limited, usually < 6 months
Symptoms do not stop (may persist for years)
Antidepressants not indicated (unless MDD is

diagnosed)
Antidepressant indicated
BEHAV02_03_
Behavioral Medicine
Sleep Physiology
Circadian Rhythm and Sleep

Circadian Rhythm
Suprachiasmatic nucleus of
hypothalamus
Serotonin, melatonin, NE,
ACh
Awake
Eyes open: beta waves
Eyes closed: alpha waves
BEHAV03_01_
Sleep Stages
N1: light sleep theta waves

N2: deeper sleep sleep spindles and K complexes
N3: deepest sleep delta waves
REM: dreaming, paralyzed, increased brain O2, erections
beta waves
NE reduces REM
Alcohol and other depressants reduce REM and sleep
stages 3 - 4
ACh is main neurotransmitter in REM sleep
BEHAV03_01_
Behavioral Medicine
Sleep Disorders
Narcolepsy
Excessive daytime sleepiness
Not necessarily asleep, just tired
Treatment
Give stimulants
BEHAV03_02_
Night Terrors vs. Nightmares

Night Terrors
Nightmares
Sleep stage
Stage 4 (delta sleep)
REM
Physiologic arousal
Extreme
Elevated
Recall upon waking
No
Yes
Waking time anxiety
Yes, usually unidentified
Yes, often unidentified
Runs in families
More common in boys
Can be a precursor to temporal
lobe epilepsy
Common from ages 3 to 7

If chronic, likelihood of serious pathology
Desensitization behavior therapy provides
marked improvement
Other issues
BEHAV03_02_
Dreams vs. Night Terrors
Dreams occur in REM

Night terrors occur in stage 3 - 4
Night terrors: screaming in middle of the night
Common in children (more common in boys)
No memory
BEHAV03_02_
Additional Sleep Disorders

Sleep patterns of depressed patients
Decreased REM latency and slow wave sleep
Increased REM early in sleep cycle and total REM sleep
Continual nighttime awakenings
Screening question: Do you have early morning
awakenings?
BEHAV03_02_
Insomnia
Common causes
Hypnotic medication abuse
Emotional problems or stress
Conditioned poor sleep
Withdrawal from drugs
Treatment
Preferred: behavioral therapy
Acute (short-term preferred) with BDZs, zolpidem, zaleplon,
eszopiclone
BEHAV03_02_
Sleep Apnea
Absence of respiration for extended periods during sleep
Patient is generally overweight
Risk of sudden death
Treatment
Weight loss
Continuous positive airway pressure (CPAP)
Condition so not sleeping on back
Surgery for severe cases
BEHAV03_02_
Sudden Infant Death Syndrome

Unexplained death in children < 1 year
Rate is higher in households where smoking is present
Fetal exposure to maternal smoking is a strong risk
factor
Treatment
Lay baby on back to sleep and avoid overstuffed
bedding & pillows
BEHAV03_02_
Somnambulism
Sleepwalking in Stage 4 (or late N-3) sleep
Treatment
Identify anxiety issues
BEHAV03_02_
Enuresis
Bedwetting that occurs in delta sleep
Defense mechanism of regression
Boys to girls: 2:1
Treatment
Acute: imipramine
Chronic: desmopressin
BEHAV03_02_ 10
Bruxism
Teeth grinding in Stage 2 (or N-2) sleep
Treatment
Reduce anxiety
Oral devices
BEHAV03_02_ 11
Behavioral Medicine
Psychiatric Illness Etiology
NR10-
Psychiatric Illness
Genetic
Environmental
Drug-induced
Personality
BEHAV04_01_
Behavioral Medicine
DSM Axes
Five Major Diagnostic Axes (Not in DSM-V)
Includes schizophrenia, mood, anxiety, and somatoform disorders

Also includes anorexia nervosa, bulimia nervosa, sexual disorders,
sleep disorders, and autism
Axis I
Clinical Disorders
Axis II
Personality disorders and

mental retardation
Personality disorders and mental retardation
Axis III
Physical conditions and

disorders
Any physical diagnosis
Axis IV
Psychosocial and
environmental problems
Includes primary support group, social occupation, education, housing,

economics, health care services, and legal issues
Axis V
Global assessment of
functioning (GAF)
Scored on a descending scale of 100 to 1, where 100 represents superior

functioning, 50 represents serious symptoms, and 10 represents persistent
danger of hurting self or others
BEHAV04_02_
Behavioral Medicine
Intellectual Development Disorder
Intellectual Development Disorder (Formerly

Mental Retardation)
Level
IQ
Functioning
Mild
70 to 50
Self-supporting with some guidance

Make up 85% of group
Two times as many are male
Usually diagnosed during grade school
Moderate
49 to 35
Benefit from vocational training, but need supervision

Sheltered workshops
Severe
34 to 20
Training not helpful

Can learn to communicate
Basic habits
Profound
Below 20
Need highly structured environment, constant nursing care supervision
BEHAV04_03_
Behavioral Medicine
Defense Mechanisms
Common Defense Mechanisms
FA 2013: 458.4-459.1
FA 2012: 482.4-483.1
FA 2011: 440.1 ME 3e: 16
Mechanism
Short Definition
Projection
Attributing inner feelings to others
Paranoid behavior
Denial
Saying it is not so
Substance abuse, reaction to death
Splitting
The world composed of polar opposites
Borderline personality; good versus evil
Blocking
Transient inability to remember
Momentary lapse
Regression
Returning to an earlier stage of development
Enuresis, primitive behaviors
Physical symptoms for psychological reasons
Somatoform disorders (now called

somatic symptom and related
disorders)
Somatization
BEHAV04_04_
Important Associations
Common Defense Mechanisms (cont.)

Mechanism
Short Definition
Fixation
Partially remaining at an earlier development

level (child-like)
Men fixating on watching and participating

in selected sports
Introjection
The outside becomes inside
Superego, being like parents
Displacement
Source stays the same, but target changes
Redirected emotion, phobias, scapegoat
Repression
Forgetting so it is non-retrievable
Forget and forget
Isolation of affect
Facts without feeling
Blunted affect, la belle indifference
Identification
Modeling ones behavior after someone who is

more powerful
An abused child models themself after an

abuser
BEHAV04_04_

Mechanism
FA 2013:
Short Definition
FA 2012: 482.4-483.1
458.4-459.1
FA 2011: 440.1 ME 3e: 16
Intellectualization
Affect replaced by academic content
Academic, not emotional, reaction
Acting out
Affect covered up by excessive action or

sensation
Substance abuse, fighting, gambling
Rationalization
Why the unacceptable is okay in this

instance
Justification, string of reasons
Reaction formation
The unacceptable transformed into its

opposite
Manifesting the opposite; feel love but show

hate: Girls have cooties.
Undoing
Action to symbolically reverse the

unacceptable
Fixing or repairing, obsessivecompulsive

behaviors
Passive-aggressive
Passive nonperformance after promise
Unconscious, indirect hostility
BEHAV04_04_
FA 2013: 458.4-459.1
FA 2012: 482.4-483.1
FA 2011: 440.1 ME 3e: 16
Mechanism
Short Definition
Dissociation
Separating self from ones own experience
Fugue, depersonalization, amnesia, multiple

personality
Humor
A pleasant release from anxiety
Laughter hides the pain
Sublimation
Moving an unacceptable impulse into an

acceptable channel
Art, literature, mentoring
Suppression
Forgetting, but is retrievable
Forget and remember
Altruism
Guilt is alleviated by generosity (unsolicited) to

others
A dishonest businessman donates money

to his church
BEHAV04_04_
Behavioral Medicine
Amnesia
Amnesia
Anterograde Amnesia
Bilateral damage to the medial temporal lobes, including the hippocampus,
results in a profound loss of the ability to acquire new information
Short term anterograde amnesia can be see with benzodiazepines
Retrograde Amnesia
Inability to remember events that occurred before the CNS injury
Dissociative Amnesia
Inability to remember pertinent personal information subsequent to CNS
injury
BEHAV04_05_
Amnesia and Orientation

Korsakoffs Amnesia
A type of anterograde amnesia caused by thiamine deficiency, seen
in alcoholics
Orientation
Patients ability to know who, when and where they are
BEHAV04_05_
Behavioral Medicine
Cognitive Disorders
Mild or Major Neurocognitive Disorder

(Formerly Cognitive Disorder)
Associated with significant changes in cognition
Memory
Attention
Language
Judgement
Problem solving
Includes
Mild neurocognitive disorder
Dementia (now known as major neurocognitive disorder)
BEHAV04_06_
Delirium Vs. Major Neurocognitive Disorder

Characteristics
Delirium
Major NCD (Dementia)
History
Acute, identifiable date
Chronic, cannot be dated
Onset
Rapid
Insidious
Duration
Days to weeks
Months to years
Course
Fluctuating
Chronically progressive
Level of consciousness
Fluctuating
Normal
Orientation
Impaired periodically
Disorientation to person
Memory
Recent memory marked impairment
Remote memories seem as recent
Perception
Visual hallucinations
Hallucinations less common
Sleep
Disrupted sleep-wake cycle
Less sleep disruption
Reversibility
Reversible
Mostly irreversible
Psychologic changes
Prominent
Minimal
Attention span
Very short
Not decreased
BEHAV04_06_
Behavioral Medicine
Neurotransmitter Changes in Selected CNS
Disorders
Neurotransmitter Changes in Selected

CNS disorders
BEHAV04_07_
Disorder
Neurotransmitter Changes
Alzheimers disease
Decreased ACh
Anxiety
Increased NE
Decreased GABA, 5-HT
Depression
Decreased NE, 5-HT, dopamine
Huntingtons disease
Increased dopamine
Decreased GABA, ACh
Parkinsons disease
Increased 5-HT, ACh

Decreased dopamine
Schizophrenia
Increased dopamine
Behavioral Medicine
Infant Deprivation
Effects of Infant Deprivation

Prolonged deprivation of affection towards an infant can cause
Poor language and socialization skills
Decreased muscle tone
The infant becoming withdrawn and unresponsive (anaclitic
depression)
Lack of trust towards adults
Physical illness and weight loss
Irreversible changes can occur when deprivation lasts > 6 months
BEHAV05_01_
Behavioral Medicine
Child Neglect and Abuse
Child Abuse
Physical abuse
Look for signs of healed fractures on x-ray, multiple bruises on unlikely
areas, burns (cigarette), and retinal damage
Mandatory reporting by physician
Sexual abuse
Look for trauma to genital, anal and oral cavities as well as evidence of STD
Peak incidence is from 9 12 years of age
Abuser is generally known to the child
BEHAV05_02_
Child Neglect
Failure to provide the child with proper food, supervision, housing,
education +/- affection
Look for malnutrition, poor hygiene, failure to thrive, impaired social
& emotional development
BEHAV05_02_
Behavioral Medicine
Attention-Deficit Hyperactivity
Disorder
Attention-Deficit Hyperactivity Disorder

Presentation
Difficulty sustaining attention
Hyperactivity and impulsivity
DSM-V: several symptoms present before age 12
Treatment
Behavior therapy
Children: methylphenidate, amphetamine salts, atomoxetine, clonidine
Adults: methylphenidate, depends of concomitant disease
BEHAV05_03_
Behavioral Medicine
Disruptive, Impulse-Control and Conduct
Disorders
Oppositional Defiant Disorder

Continual pattern of defiant and hostile behavior towards authority
figures
No serious violation of social standards
Presentation
Angry or irritable mood
Defiant behavior
Vindictiveness
BEHAV05_04_
Tourettes syndrome
Associated with motor tics and vocal tics
Diagnosed before age 18
Commonly associated with OCD and ADHD
Treatment
Alpha agonists, benzodiazepines or antipsychotic medications
BEHAV05_04_
Conduct Disorder
Repeated and pervasive behavior that violates the basic rights of
others
After the age of 18, these patients will meet the criteria for antisocial
personality disorder
BEHAV05_04_
Behavioral Medicine
Separation Anxiety Disorder
Separation Anxiety Disorder

Common age of diagnosis is 7-9 years
Profound fear of separation from attachment figure or ones home
Treatment is with SSRIs and behavioral therapy
BEHAV05_05_
Behavioral Medicine
Autism Spectrum Disorders
Autism Spectrum Disorder (DSM V)

Merges 4 former DSM-IV-TR disorders
Autistic disorder
Asperger's disorder
Childhood disintegrative disorder
Pervasive developmental disorder not otherwise specified
Behavioral disorder with problems of social interaction, speech
communication deficits and repetitive behaviors
BEHAV05_06_
Autism Spectrum Disorder (DSM V): Overview

Symptoms tend to vary across 3 core areas:
Social-interaction difficulties
Communication challenges
Tendency to engage in repetitive behaviors
Other: social anxiety, restricted interests, intellectual disability
Need for sustained support
Treatment
Behavioral shaping techniques
Medicate only if accompanied by disruptive or harmful behavior
Content from DSM-V & Other Trusted Sources
BEHAV05_06_
Autism Spectrum Disorder: Management

General characteristics
Generally diagnosed before the age of 3
Male:female ratio = 4:1
Treatment
Behavioral shaping techniques
Medication: only if accompanied by disruptive or harmful behavior
BEHAV05_06_
ASD: Special Treatment Considerations

Autistic spectrum disorders and concomitant disorders
Irritability/aggressive behavior: risperidone
Depression/anxiety: SSRIs (fluoxetine)
Repetitive behavior: SSRIs (fluoxetine or fluvoxamine)
Hyperactivity: methylphenidate
BEHAV05_06_
Aspergers Disorder
Included in ASD
Characterized by repetitive behavior, normal intelligence, allabsorbing interests and problems developing social relationships
Not associated with verbal or cognitive deficits
BEHAV05_06_
Childhood Disintegrative Disorder

Included in ASD
Profound regression in several areas of functioning after at least 2
years of normal functioning
Common age of onset/diagnosis: 3-4 years
More common in males
Dramatic loss of expressive and/or receptive language skills, social
skills and adaptive behavior
BEHAV05_06_
Behavioral Medicine
Retts Disorder
Retts Disorder
Not included in ASD

X-linked disorder
Found almost exclusively in females
Diagnosed around age 1-4 years
Characterized by loss of development, verbal abilities, intellectual
disability (mental retardation) and ataxia
Associated with stereotyped hand-wringing
BEHAV05_07_
Behavioral Medicine
Psychosis and Hallucination
Psychosis
Distorted perception of reality associated with
Hallucinations
Delusions
Disorganized thinking/speech
Etiology
Primary: schizophrenia, delusional disorder, shizoaffective disorder, etc
Secondary: drugs, dementia, CNS trauma or tumors
BEHAV06_01_
Types of Hallucination
Auditory
Associated with psychiatric illness
Gustatory
Rarely seen in psychiatric illness
Olfactory
Associated with aura of psychomotor epilepsy
Tactile
Associated with alcohol withdrawal and cocaine abuse
Visual
Associated with drug intoxication/psychiatric illness
BEHAV06_01_
Behavioral Medicine
Schizophrenia
Schizophrenia
Delusions
Hallucinations
Changes in psychomotor behavior:

loss of prosody
Disorganized speech
Negative symptoms
Blunted affect
Lack of reality testing
Disorganized behavior
Impaired concentration
Cacycle. commons.wikimedia.org.
Used with permission.
BEHAV06_02_
Schizophrenia: Negative Symptoms
Uncooperative, flat affect, motor retardation, mutism

Apathy
Neglect of personal hygiene
Social withdrawal
Reduced ability to plan or carry out activities
Not treated by typical antipsychotics but treated with atypical
antipsychotics
BEHAV06_02_
Schizophrenia: Differential Diagnosis

< 1 month: brief psychotic episode
16 months: schizophreniform disorder
Psychotic symptoms + signs of depression / mania for 2 weeks:
evaluate for schizoaffective disorder
DSM-V: a mood disorder must be present for the majority of the
disorders duration for a diagnosis of schizoaffective disorder
BEHAV06_02_
Schizophrenia Subtypes
DSM-V diagnostic criteria no longer identifies subtypes
Paranoid
Delusions of persecution or grandeur
Often accompanied by hallucinations (voices)
Catatonic
Complete stupor or pronounced decrease in spontaneous
movements
BEHAV06_02_
Disorganized
Incoherent, primitive, uninhibited
Unorganized behaviors and speech
Undifferentiated
Psychotic symptoms but does not fit paranoid, catatonic, or
disorganized diagnoses
BEHAV06_02_
Residual
Previous episode, but no prominent psychotic symptoms at
evaluation
Some lingering negative symptoms
BEHAV06_02_
Behavioral Medicine
Schizophrenia Management
Schizophrenia: Treatment Overview

Treatment of schizophrenia should be based on the following
Adverse effects of the medication
Patient presentation
Previous interventions
Pregnancy
BEHAV06_03_
Schizophrenia: General Interventions
Social support
Suicide prevention and monitoring for depression
Health maintenance
Co-morbidities
BEHAV06_03_
Behavioral Medicine
Antipsychotics
First - Generation (Typical) Antipsychotics

High Potency
Haloperidol, trifluoperazine, fluphenazine
Cause more EPS and less nonspecific side effects
Low potency
Chlorpromazine, thioridazine
Cause less EPS and more nonspecific side effects
Mechanism of action
Selective antagonism of dopamine D2 receptors
BEHAV06_04_
First - Generation (Typical) Antipsychotics:

Non- Specific Side Effects
Due to alpha-blockade and antimuscarinic effects
Orthostatic hypotension, male sexual dysfunction ( blockade)
Constipation, dry mouth, urinary retention, visual problems
(muscarinic blockade)
Sedation
BEHAV06_04_
First - Generation (Typical) Antipsychotics:

Other Side Effects
Hyperprolactinemia
D2-receptor blockade in the pituitary
Neuroleptic malignant syndrome
Muscle rigidity, hyperthermia, and autonomic instability
Treatment: dantrolene or dopamine agonists
Extrapyramidal symptoms
Acute dystonia, akathisia, bradykinesia (parkinsonism), tardive dyskinesia
BEHAV06_04_
First-generation (typical) Antipsychotics:

Other Side Effects (Contd)
Dystonia
Involuntary contractions
Responds to anticholinergics
Parkinsonism
Akinesia, muscle rigidity, tremor, shuffling gait
Akathisia
Motor restlessness and the urge to move
BEHAV06_04_
First-generation (typical) Antipsychotics:

Other Side Effects (Contd)
Tardive dyskinesia
Requires exposure to neuroleptics for at least 3 months
Involuntary repetitive movements of lips, face, tongue, limbs
Prevent by using lowest possible dose of antipsychotic medication
Anticholinergics worsen TD
Try to reduce dose or discontinue medication if TD occurs
Switch to an atypical antipsychotic
BEHAV06_04_
Second - Generation (Atypical) Antipsychotics

Examples
Risperidone, olanzapine, quetiapine, ziprasidone, aripiprazole, clozapine
Mechanism of action
5HT2 antagonists and weaker D2 antagonists
Note: clozapine blocks D4, rather than D2 receptors
Characteristics
Treat positive & negative symptoms of schizophrenia
Uses: schizophrenia, BPD, OCD, anxiety disorder, depression, Tourettes
BEHAV06_04_
Second - Generation (Atypical) Antipsychotics:

Selected Side Effects
Less EPS
Clozapine: agranulocytosis
Clozapine and olanzapine: weight gain
Ziprasidone: prolongs QT interval, may lead to torsades
Risperidone: higher risk of EPS
BEHAV06_04_
Behavioral Medicine
Dissociative Disorders
Delusional and Depersonalization/Derealization

Disorders
Delusional Disorder
Persistent, non-bizarre (non-bizarre removed in DSM-V) delusional
beliefs > 1 month with no other functional impairment
Depersonalization/derealization disorder
Consistent feelings of detachment from ones own body or
environment
BEHAV06_05_
Dissociative Fugue and Dissociative Identity

Disorder
Dissociative fugue
Eliminated in DSM-V as individual diagnosis
Now a specifier under dissociative amnesia
Dissociative identity disorder
Presence of > 2 distinct identities or personalities
May be observable by others or self
May have recurrent gaps in recall for everyday events
BEHAV06_05_
Behavioral Medicine
Mood Disorder
Mood Disorder
Characterized by a disturbance in the persons mood and loss of
control over that mood
Associated with personal distress and impairment with familial,
social and/or occupational functioning
Mood Disorders: Summary
Mild form
Severe form
Stable
Dysthymia *
Major depressive disorder
Alternating
Cyclothymic disorder
Bipolar disorder
*Now persistent depressive disorder in DSM-V
BEHAV07_01_
Behavioral Medicine
Bipolar Disorders
Mania
State of abnormally elevated, expansive or irritable mood, arousal and/or
energy levels for > 1 week
BEHAV07_02_
Symptoms (DIG FAST)
Explanation
Distractibility
Inability to concentrate
Interest, Irresponsibility,
Increased energy (DSM V)
Pleasure seeking without regard for consequences;

increased energy/activity is a core symptom (DSM-V)
Grandiosity
Inflated self-esteem
Flight of ideas
Racing thoughts
Appetite or Agitation
Both dramatically increased
Sleep
Decreased need for sleep
Talkativeness
Loud and pressured speech
Hypomania
Criterion A revised in DSM-V to include increased energy/activity as
a core symptom
Does not cause marked impairment in occupational and/or social
functioning
No need for hospitalization
No psychotic features
BEHAV07_02_
Cyclothymic Disorder
Alternating states of dysthymia (now persistent depressive disorder
in DSM-V) and hypomania
Milder form of bipolar disorder
Chronic (lasting at least 2 years)
Often not recognized by affected person
BEHAV07_02_
Bipolar Disorder: Overview

Symptoms of major depressive disorder and symptoms of mania
DSM-V
Criteria A: emphasis on changes in activity and energy as well as
mood
Bipolar I
Bipolar II
Rapidly cycling bipolar disorder (48 72 hours)
New specifier: mixed features

BEHAV07_02_
Bipolar Disorder: Classification

DSM-5: new specifier "with mixed features" can be applied to bipolar
I disorder, bipolar II disorder, bipolar disorder NED (previously called
"NOS") and MDD (major depressive disorder)
Manic symptoms
activity/energy, grandiosity, need for sleep, flight of ideas,
weight loss, erratic and uninhibited behavior, libido
BEHAV07_02_
Bipolar Disorder: Management

Mood Stabilizers or atypical antipsychotics
Examples: lithium, lamotrigine, valproic acid, olanzapine,
aripiprazole, ziprasidone, asenapine
Psychosocial intervention
Adjunct therapy: electroconvulsive therapy (ECT)
BEHAV07_02_
Behavioral Medicine
Mood Stabilizers
Bipolar Disorder: Lithium

Primarily used in bipolar disorder (BPD)
Theoretically it inhibits recycling of neuronal phosphoinositide; altering
neuronal sodium transport
Very narrow therapeutic index: requires monitoring
Side effects
Reversible nephrogenic diabetes insipidus (manage with amiloride)
Hypothyroidism with goiter
Other: sedation, ataxia, tremor, edema, acne, leukocytosis
Neonatal toxicity (Ebsteins anomaly)
BEHAV07_03_
Bipolar Disorder: Other Treatment Options

Valproic acid and lamotrigine
Atypical antipsychotics
Olanzapine
Aripiprazole
Ziprasidone
Asenapine
BEHAV07_03_
Behavioral Medicine
Depressive Disorders
Persistent Depressive Disorder

Formerly dysthymia
PDD includes both chronic major depressive disorder and the
previous dysthymic disorder
Considered a mild form of major depressive disorder
Chronic condition lasting > 2 years
Loss of interest or pleasure
BEHAV07_04_
Seasonal Affective Disorder

DSM-V change: SAD not considered to be a unique diagnostic entity
Primarily depressive symptoms during winter months
Hypomania or manic symptoms during spring or summer months
Believed to be caused by abnormal melatonin metabolism/alteration of 5-HT
Patients respond well to bright light therapy
SSRIs when unresponsive to bright light therapy
BEHAV07_04_
Major Depressive Disorder: Overview

The core criterion symptoms for diagnosis, the requisite duration of
at least 2 weeks and criterion A for a major depressive episode in
DSM-V is identical to that of DSM-IV-TR
Bereavement exclusion was removed for depressive disorders in
DSM-V
Self-limiting disorder with episodes generally lasting 6-12 months
BEHAV07_04_
Major Depressive Disorder: Diagnosis

5 of the following must be present for at least 2 weeks + 1 of the 5
symptoms must be depressed mood or anhedonia
BEHAV07_04_
Amotivation
Feelings of worthlessness
Decreased concentration
Weight changes
Insomnia or hypersomnia
Recurrent thoughts
Psychomotor agitation or retardation

Somatic complaints
Delusions or hallucinations
Loss of sex drive
Suicidal ideation
Major Depressive Disorder: Other Characteristics

Neurochemistry
Biogenic amine theory of depression caused by NE/5HT
Sleep changes
REM in first half of sleep
REM latency
stage 4 sleep
REM time overall
Early morning wakening
BEHAV07_04_
Behavioral Medicine
Antidepressants
Major Depressive Disorder: TCAs

Examples: amitriptyline, imipramine, nortriptyline, desipramine
MOA: block reuptake of NE and 5HT
Indications
Major depressive disorder
Neuropathic pain
Other: phobias, OCD, enuresis
Side effects mediated through muscarinic and alpha-blockade
Other: sedation, seizure threshold
Overdose: coma, convulsions, cardiotoxicity
Drug interactions
BEHAV07_05_
Major Depressive Disorder: MAOIs

Examples: phenelzine, tranylcypromine, isocarboxazid
MOA: interferes with metabolism of NE and 5HT by blocking MAO A
and B
Side effects: orthostatic hypotension, weight gain
Hypertensive crisis if patient consumes food with tyramine and other
indirect-acting sympathomimetics
Serotonin syndrome when combined with SSRIs
BEHAV07_05_
Major Depressive Disorder: SSRIs

Examples: fluoxetine, sertraline, citalopram, fluvoxamine, paroxetine
MOA: blocks reuptake of 5HT
Indications
Major depression
Other: OCD, bulimia, panic disorder, PMDD, GAD and bipolar disorder
Side effects: anxiety, agitation, bruxism, sexual dysfunction, weight loss

Serotonin syndrome
Seizures occurs with TCAs, MAOIs, meperidine, dextromethorphan
BEHAV07_05_
Major Depressive Disorder: SNRIs

Examples: venlafaxine, desvenlafaxine, duloxetine
MOA: inhibits serotonin and norepinephrine reuptake
Indications
Major depression
Venlafaxine and desvenlafaxine: GAD and panic disorders
Duloxetine: peripheral neuropathy
BEHAV07_05_
Major Depressive Disorder: Trazodone

Indications
Depression (second line) + insomnia
Mechanism of action
Inhibits serotonin reuptake
Antagonizes alpha-1 adrenergic and serotonin 5-HT2A/C receptors
Side effects
Sedation, priapism
BEHAV07_05_
Major Depressive Disorder: Bupropion

Indications
Depression (second line) + smoking cessation
Mechanism of action
Inhibits neuronal uptake of NE & dopamine
Side effects
Tachycardia, insomnia, headache, seizures
No sexual side effects
BEHAV07_05_
Major Depressive Disorder: Mirtazapine

Indications
Depression (second line) + depression in anorexia nervosa
Mechanism of action
Antagonizes alpha-2 adrenergic and serotonin 5-HT2 receptors
Side effects
Weight gain
BEHAV07_05_
Major Depressive Disorder: Maprotiline

Second line antidepressant that acts by blocking NE reuptake
Side effects
Seizures
Cardiotoxicity
Orthostatic hypotension
BEHAV07_05_
Behavioral Medicine
Electroconvulsive Therapy
Major Depressive Disorder: ECT Indications
Depression (80%)
Good for suicidal patients and pregnant patients
Schizoaffective disorder (10%)
Bipolar disorder
90% of patients show improvement
Full effect generally evident after 5 to 10 treatments
Anesthesia eliminates fractures and anticipatory anxiety
BEHAV07_06_
Major Depressive Disorder: ECT Side Effects

Memory loss and headache common
Returns to normal in several weeks
Contraindication
intracranial pressure
BEHAV07_06_
Behavioral Medicine
Atypical Depression
Atypical Depression
Unlike typical depression, there is mood reactivity
Treatment
MAOIs or SSRIs
BEHAV07_07_
Behavioral Medicine
Postpartum Depressive Disorders
Postpartum Depression
Depressed affect, poor concentration, anxiety
DSM-V has new specifier with peripartum onset
Treatment
Antidepressants +/- psychotherapy
BEHAV07_08_
Postpartum Blues
Not in DSM-V
MMD following pregnancy use with peripartum onset specifier
Depressed affect, tearfulness and fatigue
Treatment
Supportive with follow-up to assess for progression to postpartum
depression
BEHAV07_08_
Postpartum Psychosis
Presentation
Hallucination, delusions, confusion
Odd behavior as well as suicidal/homicidal ideation or attempts
Treatment
Antipsychotics, antidepressants and potentially hospitalization
BEHAV07_08_
Behavioral Medicine
Premenstrual Dysmorphic Disorder
Premenstrual Dysmorphic Disorder: Overview

In DSM-IV-TR was classified as depressive disorder not otherwise
classified
Premenstrual dysphoric disorder is now an official diagnosis in the
DSM-V
BEHAV07_09_
Premenstrual Dysmorphic Disorder: Diagnosis

Most menstrual cycles during past year, five (or more) of the following
symptoms occurred during final week before onset of menses, starts
improving within a few days after onset of menses, and are minimal or
absent in week post-menses, with at least one of the symptoms being
either (1), (2), (3), or (4)
BEHAV07_09_
Premenstrual Dysmorphic Disorder: Criteria
Symptoms (1- 4)
Other symptoms (5 - 11)
Marked affective liability

Marked irritability or anger or
increased interpersonal
conflicts
Markedly depressed mood,
feelings of hopelessness, selfdeprecating thoughts
Marked anxiety, tension,
feelings of being keyed up or
on edge
Decreased interest in usual

Subjective sense of difficulty in concentration
Lethargy, easy fatigability, or marked lack of energy
Marked change in appetite
Hypersomnia or insomnia
Subjective sense of being overwhelmed or out of
control
Other physical symptoms: breast tenderness or
swelling, joint or muscle pain, a sensation of bloating,
weight gain
BEHAV07_09_
Premenstrual Dysmorphic Disorder: Management

Lifestyle changes
SSRIs (fluoxetine)
BEHAV07_09_
Behavioral Medicine
Disruptive Mood Dysregulation Disorder
Disruptive Mood Dysregulation Disorder

Previously labeled as childhood bipolar disorder
Can be diagnosed in children up to age 18 years
Presentation
Persistent irritability and frequent episodes of extreme, out-of-control
behavior
BEHAV07_10_
Behavioral Medicine
Anxiety Disorders
Anxiety Disorder: Overview

Characterized by excessive fear or worry and its associated with
physical manifestations
Inability to control inappropriate feelings resulting in an impairment
with familial, social and/or occupational functioning
Anxiety disorders are the most common type of psychiatric disorder
in women and one of the most common in men
BEHAV08_01_
Anxiety Disorder: Classification
Generalized anxiety disorder (GAD)

Panic disorders
Specific phobias & social anxiety disorder
Obsessive-compulsive disorder (OCD) *
DSM-V: OCD is in the obsessive compulsive and related
disorders chapter
Post-traumatic stress disorder (PTSD) *
DSM-V: PTSD is in the trauma and stress related disorders
chapter
BEHAV08_01_
Anxiety Disorders: Updated List

List of Anxiety Disorders in DSM-V
Separation anxiety disorder

Selective mutism
Specific phobia
Social anxiety disorder (social
phobia)
Panic disorder
Panic attack (specifier)
Agoraphobia
BEHAV08_01_
Generalized anxiety disorder

Substance/medication-induced
anxiety disorder
Anxiety disorder due to another
medical condition
Other specified anxiety disorder
Unspecified anxiety disorder
Behavioral Medicine
Generalized Anxiety Disorder
Generalized Anxiety Disorder: Overview

Symptoms exhibited more days than not > 6-month period
3 key symptoms (out of 6) required diagnose
Restlessness or nervousness
Easy fatigability
Poor concentration
Irritability
Muscle tension
Sleep disturbance
Exclude: medications or substance abuse, medical condition causing the
symptoms and other mental disorder
BEHAV08_02_
Generalized Anxiety Disorder: Management

Cognitive behavioral therapy (CBT)
Acute pharmacological treatment
Benzodiazepines
Chronic pharmacological treatment
First line: buspirone, SSRIs, SNRIs
Second line: TCAs, atypical antipsychotics
BEHAV08_02_
Behavioral Medicine
Antianxiety Medications
Generalized Anxiety Disorder: Benzodiazepines

Drug
Indication
Alprazolam
Anxiety, panic, phobias
Chlordiazepoxide
Alcohol detoxification
Clonazepam
Panic disorder, anxiety, seizures
Diazepam
Anxiety, preop sedation, muscle relaxation, withdrawal states
Lorazepam
Anxiety, preop sedation, status epilepticus (IV)
Midazolam
Preop sedation, anesthesia (IV)
Temazepam
Sleep disorders
Oxazepam
Sleep disorder, anxiety
BEHAV08_03_
Generalized Anxiety Disorder: BZDs Effects

Mechanism of action
Binds GABAA receptor and frequency of Cl- ion channel opening
Act through the benzodiazepine receptors
BZ1: mediates sedation
BZ2: mediates antianxiety and impairment of cognitive functions
Dose-dependent CNS depression
Not metabolized in liver
Out The Liver: Oxazepam, Temazepam, Lorazepam
BEHAV08_03_
Generalized Anxiety Disorder: Buspirone

Used for chronic treatment of anxiety
Stimulates 5HT1A receptors and may have effect on D2 receptors
Advantages
Not associated with sedation, addiction, tolerance
Does not interact with alcohol
Disadvantages
1-2 weeks to begin working
BEHAV08_03_
Generalized Anxiety Disorder: Other Treatment

First-line therapies
SSRIs: paroxetine, escitalopram, sertraline
SNRIs: duloxetine and venlafaxine
Second-line therapies
TCAs & atypical antipsychotics: used when patients are
unresponsive to buspirone, SSRIs or SNRIs
BEHAV08_03_
Behavioral Medicine
Panic Disorder
Panic Disorder: Overview

Associated with recurring expected or unexpected panic attacks,
worry about future attacks over a 1-month period and changes in
behavior as a result of the attacks.
Panic disorder and agoraphobia are unlinked in DSM-V
Panic attack: abrupt onset of symptoms, peak within 10 minutes
Panic attack can be listed as a specifier that is applicable to all
DSM-V disorders
BEHAV08_04_
Panic Disorder: Presentation
Apprehension, fear, palpitations

Trembling, sweating
Chest pain
Nausea
Sense of unreality
Fear of dying or going crazy
Hyperventilation, air hunger + shortness of breath
BEHAV08_04_
Panic Disorder: Management

Acute therapy
Cognitive behavioral therapy +/- alprazolam or clonazepam
Chronic therapy (daily use)
First line: SSRIs or SNRIs
Second-line: TCAs
BEHAV08_04_
Behavioral Medicine
Specific Phobias
Specific Phobia
DSM-V: no longer a requirement that individuals > 18 years must
recognize that their fear and anxiety are excessive or unreasonable
Duration requirement lasting 6 months applies to all ages
Persistent disabling fear that is recognized by the person
Treatment
Systematic desensitization
BEHAV08_05_
Behavioral Medicine
Social Anxiety Disorder
Social Anxiety Disorder: DSM-V Update

Formerly social phobia
Essential core features of this disorder remain the same in DSM-IV
Changes in DSM-V
Deletion of requirement that individuals > age 18 years must
recognize that their fear or anxiety is excessive or unreasonable
Duration of typically lasting > 6 months is now required for all ages
Generalized specifier has been deleted and replaced with a
performance only specifier
BEHAV08_06_
Social Anxiety Disorder: Characteristics

Excessive fear of social and performance situations where the
person is fearful of being embarrassed or negatively evaluated by
others
Leads to dysfunctional guarded behavior
May accompany avoidant personality disorder
BEHAV08_06_
Social Anxiety Disorder: Management

Paroxetine or atenolol or propranolol
Generalized social anxiety: phenelzine or paroxetine
Discrete performance anxiety
Most common phobia
Paroxetine or atenolol or propranolol
BEHAV08_06_
Behavioral Medicine
Obsessive Compulsive and Related
Disorders
Obsessive Compulsive and Related Disorders

Obsessive-compulsive
disorder formerly an anxiety
disorder
Body dysmorphic disorder
formerly a somatoform
disorder
Hoarding disorder new
disorder
Trichotillomania new
classification
BEHAV08_07_
Excoriation disorder new

disorder
Substance/medication-induced
obsessive-compulsive and
related disorder new disorder
Obsessive-compulsive &
related disorder due to another
medical condition new
disorder
OCD and Related Disorders: Management

Obsessions and/or compulsions that cause marked distress and
interfere dramatically with the person's lifestyle,
occupational/academic functioning and/or social activities and
relationships
Obsession: focusing on one thought, usually to avoid another
Compulsion: repetitive action shields person from thoughts, action
fixes bad thought
Treatment
CBT +/- SSRI or clomipramine
BEHAV08_07_
Behavioral Medicine
Body Dysmorphic Disorder
Body Dysmorphic Disorder: DSM-V Update

Formerly classified as a somatoform disorder
Somatoform disorders were renamed somatic symptom and related
disorders
Analogous specifier to OCD: allows distinction between individuals
Good or fair insight
Poor insight
Absent insight/delusional beliefs
There is a with muscle dysmorphia specifier
BEHAV08_08_
Body Dysmorphic Disorder: Management

Focus on a physical defect that is not evident to others
Example: defect in shape of ones nose, muscles not big enough
Specific characteristics include
Preoccupation with an imagined defect in ones appearance
Possibly associated with multiple, desperate, and unsuccessful
attempts to correct imagined defect by cosmetic surgery
Treatment
CBT +/- SSRIs (decrease symptoms in up to 50% of patients)
BEHAV08_08_
Behavioral Medicine
Trauma and Stress Related
Disorders
Trauma- and Stress-Related Disorders: DSM-V

List the disorders in this chapter in DSM-V
Reactive attachment disorder
Disinhibited social engagement disorder
Posttraumatic stress disorder
Acute stress disorder
Adjustment disorders
Other specified trauma- and stressor-related disorder
Unspecified trauma- and stressor-related disorder
BEHAV08_09_
Post Traumatic Stress Disorder: DSM-V Update

Formerly an anxiety disorder in DSM-IV-TR
Criterion A now requires whether qualifying traumatic events were
experienced directly, witnessed, or experienced indirectly
Deletion of subjective reaction to the traumatic event
Addition of criteria for children < 6 years of age
Alterations in arousal and reactivity cluster now contains irritable or
aggressive behavior and reckless or self-destructive behavior
BEHAV08_09_
Post Traumatic Stress Disorder: Management

Disorder that develops after exposure to a stressful event/situation of a
profoundly threatening or catastrophic nature
4 groups of symptoms
Re-experiencing event
Avoidant behavior
Persistent negative alterations in cognitions and mood
Hyperarousal
Treatment
Trauma-focused CBT +/- SSRI
BEHAV08_09_
Behavioral Science
Somatic Symptom and Related Disorders
Somatic Symptom and Related Disorders: DSM-V

Formerly somatoform disorders (DSM-IV-TR)
Defined as disturbing physical symptoms not fully explained by other
medical, neurologic, or psychiatric disorders
DSM-V deleted the following
Somatization disorder
Undifferentiated somatoform disorder
Hypochondriasis
Pain disorder
BEHAV09_01_
Somatic Symptom and Related Disorders

The following is a list of disorders included in this DSM-V chapter
Somatic symptom disorder
Illness anxiety disorder
Conversion disorder (functional neurological symptom disorder)
Psychological factors affecting other medical conditions
Factitious disorder
Other specified somatic symptom and related disorder
Unspecified somatic symptom and related disorder
BEHAV09_01_
Somatic Symptom and Related Disorders:

Reclassification
Assuming that the patient meets the diagnostic criteria for the
appropriate DSM-V disorder, patients previously diagnosed with a
DSM-IV-TR disorder (on the left) would be likely placed with a DSMV disorder (on the right)
Somatization disorder
Illness anxiety disorder
Hypochondriasis
Somatic symptom disorder
Pain disorder
Adjustment disorder
Undifferentiated
somatoform disorder
Psychological factors affecting

other medical conditions
BEHAV09_01_
Somatic Symptom Disorder: Overview

Somatic symptoms are distressing physical symptoms that are not fully
explained by other medical, neurologic, or psychiatric disorders
Patients must have excessive thoughts, feelings, or behaviors related to the
somatic symptoms or associated health concerns as manifested by at least
one of the following
Disproportionate and persistent thoughts about the seriousness of one's
symptoms
Persistently high levels of anxiety about health or symptoms
Excessive time or energy devoted to these symptoms or health
concerns
BEHAV09_01_
Somatic Symptom Disorder: Management

CBT or some form of psychotherapy
Comorbid anxiety: benzodiazepine +/- SSRI
Comorbid depression: SSRI, SNRI or second-line atypical
antipsychotic
Comorbid pain syndrome: TCAs or duloxetine
BEHAV09_01_
Behavioral Medicine
Illness Anxiety Disorder
Illness Anxiety Disorder

High health anxiety without the presence of somatic symptoms
Diagnostic Criteria
Complete absence of somatic symptoms,

or if any somatic symptoms are present,
they are minimally preset and very mild
Continuous worrisome preoccupation with
thinking that a serious medical condition is
present
Very high levels of health anxiety and
anxiety about having acquired a serious
medical condition
Performance of related extremely excessive

behavior
State of being preoccupied constantly by concerns
for health has existed for at least 6 months. The
preoccupation may become inconsistent at times
The Illness anxiety disorder is not caused by
another disorder, such as panic disorder or
generalized anxiety disorder
Treatment: CBT +/- benzodiazepine +/- SSRI or SNRI

BEHAV09_01_
Behavioral Medicine
Functional Neurological Symptom
Disorder
Conversion Disorder (Functional Neurological

Symptom Disorder): Presentation
Formerly conversion disorder
Characterized by a rapid and sudden loss of neurological function
No evidence that the symptom is artificially or intentionally produced
Loss of function that is not due to medical illness or culturally expected
behavioral response
Generally occurs following a severe stressor
Specific characteristics include
1 symptoms of loss of voluntary motor or sensory function
Psychological issues felt important in initiation or exacerbation of loss of
function
BEHAV09_03_
Conversion Disorder (Functional Neurological

Symptom Disorder) : Management
Psychosocial treatment
Hypnosis
Cognitive behavioral therapy
Comorbid anxiety: benzodiazepine +/- SSRI
Comorbid depression: SSRI, SNRI or second-line atypical
antipsychotic
BEHAV09_03_
Behavioral Medicine
Factitious Disorders
Factitious Disorder Imposed on Self: Presentation

Characterized by an intentional (conscious) creation of physical
and/or psychological symptoms in an effort to portray sickness and
obtain medical attention
Patients may provide false medical history
Manipulation of diagnostic instruments
Manipulation of diagnostic tests
Inducing a medical illness
Any combination of the above
BEHAV09_04_
Factitious Disorder Imposed on Self: Management

Psychotherapy
Cognitive behavioral therapy (only if patient is willing to cooperate)
SSRIs may provide benefit
BEHAV09_04_
Factitious Disorder Imposed on Self or Others

Formerly Munchausen syndrome
An intentional overstated, artificial, simulated, aggravated, or selfinduced illness or injury for the primary purpose of assuming the sick
role
Diagnosis requires that external incentives for the behavior are
absent
Patients often have a history of numerous hospital admissions and
a willingness to receive invasive procedures
BEHAV09_04_
Factitious Disorder Imposed on Another

Formerly Munchausen syndrome by proxy
The perpetrator intentionally produces or feigns physical or
psychological signs or symptoms in another person who is under
their care
The primary motivation for the perpetrators behavior is to assume
the sick role by proxy
Diagnosis requires that external incentives for behavior are absent
Another mental disorder does not account for the behavior
Generally involves children or the elderly (form of child/elder abuse)
BEHAV09_04_
Behavioral Medicine
Malingering
Malingering: Overview
Not considered a mental illness
Intentional production of false or grossly exaggerated physical or
psychological symptoms, motivated by external incentives such as
avoiding military duty, avoiding work, obtaining financial
compensation, evading criminal prosecution, or obtaining drugs
Poor compliance with treatment or follow-up diagnostic tests
Complaints generally decline after secondary gain is achieved
BEHAV09_05_
Malingering: Management
No treatment is recommended
Patient should be approached and indicate that the objective
findings do not meet the criteria for the desired diagnosis
BEHAV09_05_
Behavioral Science
Personality Disorders
Personality Disorder - Changes in DSM-V

DSM-V combines the first three DSM-IV-TR axes into one list that
contains all mental disorders, including the two former Axis II
disorders: personality disorders and intellectual disability disorder
BEHAV10_01_
Personality: Overview
A continuing, repetitive pattern of relating to, perceiving and thinking about
the surroundings and oneself
Personality may be expressed in terms of these 5 basic dimensions
Extraversion
Agreeableness
Conscientiousness
Neuroticism
Openness to experience
Personality disorders may be differentiated by their interactions among the
5 dimensions rather than differences on any single dimension
BEHAV10_01_
Personality Disorder
Pervasive pattern of behavior causing distress and impaired
functioning
Personality Disorders by Cluster
Cluster A
Cluster B
Cluster C
Paranoid personality
disorder
Schizoid personality
disorder
Schizotypal
Antisocial personality disorder

Borderline personality
disorder
Histrionic personality disorder
Narcissistic personality
disorder
Avoidant personality disorder

Dependent personality
disorder
Obsessive-compulsive
BEHAV10_01_
Behavioral Medicine
Personality Disorders
Cluster A: Paranoid Personality Disorder

Characterized by feelings of persecution
Feels that others are conspiring to harm them
Very suspicious of others
Epidemiology
Men > women
Increased incidence in families with schizophrenia
Associated defenses
Projection
BEHAV10_02_
Cluster A: Schizoid Personality Disorder

Characterized by an isolated lifestyle
Has no longing for others (loner)
Content with social isolation (in contrast to avoidant PD)
Epidemiology
Men > women
Increased incidence in families with schizophrenia
Associated defenses
None
BEHAV10_02_
Cluster A: Schizotypal Personality Disorder

Characterized by eccentric behavior
Thoughts and speech as well as magical thinking
Epidemiology
Men > women
Prevalence of 3%
Associated defenses
None
BEHAV10_02_
Cluster A: Management
Relationship management strategies
(+/-) Low-dose antipsychotics
Aripiprazole, haloperidol
(+/-) Antidepressants
SSRI or SNRI
BEHAV10_02_
Cluster B: Histrionic Personality Disorder

Characterized by excessive emotion and attention
Patients tend to be overly concerned with appearance
Sexually provocative
Epidemiology
Women > men
Underdiagnosed in men
Associated defenses
Regression, somatization, conversion, dissociation
BEHAV10_02_
Cluster B: Narcissistic Personality Disorder

Characterized by sense of entitlement and grandiosity
Requires excessive admiration
Over concerned with issues of self-esteem
Reacts to criticism with rage
Epidemiology
Common
Associated defenses
Fixation at sub phase of separation/individualization
BEHAV10_02_
Cluster B: Antisocial Personality Disorder

Characterized by a continual disregard for the rights of others (or self)
Pervasive lying and deception with continual lack of remorse
Physical aggressiveness and continued violations of law
Consistent irresponsibility in work and familial environment
Epidemiology
Prevalence: Men (1%) and Women (3%)
Associated defenses
Superego lacunae
BEHAV10_02_
Histrionic, Narcissistic and Antisocial PD:

Management
Patient communication
Substance abuse treatment program referral (if needed)
BEHAV10_02_
Cluster B: Borderline Personality Disorder

Characterized by instability of mood, self-image and relationships
Frantic efforts to avoid expected abandonment
Inappropriate and intense anger
Epidemiology
Women > men
Increased mood disorders in families
Associated defenses
Splitting, projective identification, dissociation, passive-aggressive
BEHAV10_02_ 10
Borderline Personality Disorder: Management

Psychotherapy
(+/-) Mood stabilizers (lithium)
(+/-) Anticonvulsants (lamotrigine, divalproex, topiramate)
Substance abuse treatment program (if needed)
BEHAV10_02_ 11
Cluster C: Avoidant Personality Disorder

Characterized by profound fear of rejection but desires relationships
Feeling of inadequacy and tend to be shy and timid
Epidemiology
Common
Associated defenses
Avoidance
BEHAV10_02_ 12
Cluster C: Dependent Personality Disorder

Characterized by profound need to be taken care of
Person is dependent on another and very submissive
Epidemiology
Common
Women > Men
Could potentially end up as an abused spouse
Associated defenses
None
BEHAV10_02_ 13
Cluster C: Obsessive-compulsive Personality

Disorder
Characterized by perfectionistic behavior that is inflexible, orderly
and rigid
Obsessive and compulsive about their own beliefs (vs OCD)
Epidemiology
Men > women
Increased concordance in identical twins
Associated defenses
Isolation, reaction formation, undoing, intellectualization
BEHAV10_02_ 14
Cluster C: Management
Patient communication
Psychotherapy
Substance abuse treatment program (if needed)
BEHAV10_02_ 15
Behavioral Science
Feeding and Eating Disorders
BEHAV11_01_
Feeding and Eating Disorders: DSM-V Update

Addition of binge eating disorder as its own disorder in DSM-V
Updated diagnostic criteria for anorexia and Bulimia Nervosa
The disorders in the feeding and eating disorders chapter are:
Pica
Rumination disorder
Avoidant/restrictive food
intake disorder
Anorexia nervosa
BEHAV11_01_
Bulimia nervosa
Binge eating disorder
Other specified feeding or eating
disorder
Unspecified feeding or eating disorder
Feeding and Eating Disorder: Overview

Persons with eating disorders tend to have a distorted body image
Feeding and eating disorder frequently appear during teen years or young
adulthood but may also develop during childhood or later in life
3 most common eating disorders
Anorexia nervosa
Bulimia nervosa
Binge eating disorder
BEHAV11_01_
Behavioral Medicine
Anorexia Nervosa
Anorexia Nervosa: Overview

Persistent restriction of energy intake leading to significantly low
body weight
Either an intense fear of gaining weight or of becoming fat, or
persistent behavior that interferes with weight gain (even though
significantly low weight)
Disturbance in the way one's body weight or shape is experienced,
undue influence of body shape and weight on self-evaluation, or
persistent lack of recognition of the seriousness of the current low
body weight
BEHAV11_02_
Anorexia Nervosa: Presentation
Excessive dieting
+/- increased exercising
+/- binging/purging
+/- overuse of laxatives/diuretics
Intense fear of gaining weight and distorted body image
Lack of menstruation with females (removed in DSM-V)
BEHAV11_02_
Anorexia Nervosa: Complications

Osteopenia or osteoporosis
Brittle hair and nails
Electrolyte disturbances
Anemia and muscle wasting/weakness
Other
Constipation
Hypotension, bradypnea
Dry-yellowish skin with lanugo
BEHAV11_02_
Anorexia Nervosa: Management
Structured eating plan

Psychotherapy
Electrolyte repletion
SSRIs if depression or OCD also present
BEHAV11_02_
Behavioral Medicine
Bulimia Nervosa
Bulimia Nervosa: Overview

Recurrent episodes of binge eating
Recurrent inappropriate compensatory behavior in order to prevent
weight gain, such as self-induced vomiting, misuse of laxatives,
diuretics, or other medications, fasting, or excessive exercise
Binge eating and inappropriate compensatory behaviors both occur,
on average, at least once a week for three months
Self-evaluation is unduly influenced by body shape and weight
Does not occur exclusively during episodes of anorexia nervosa
BEHAV11_03_
Bulimia Nervosa: Presentation

Recurrent and frequent episodes of eating unusually large amounts of food
and feeling a lack of control over these episodes followed by behavior that
compensates for the overeating
Forced vomiting: several times/week to several times/day
Excessive use of laxatives or diuretics
Fasting
Excessive exercise
Normal body weight but intense fear of gaining weight & distorted body
image
Behavior is generally secretive
BEHAV11_03_
Bulimia Nervosa: Complications

Enamel erosion
Dorsal hand calluses
Electrolyte disturbances
Other
GERD
Parotitis
Alkalosis, dehydration
Cardiac abnormalities
BEHAV11_03_
Bulimia Nervosa: Management
Cognitive behavioral therapy

Nutritional support
Psychotherapy
Electrolyte repletion
SSRIs or SNRIs if depression, OCD, or PTSD are also present
BEHAV11_03_
Behavioral Medicine
Binge Eating Disorder
Binge Eating Disorder: Overview

Recurrent episodes of binge eating associated with 3 of the following:
Eating much more rapidly than normal
Eating until feeling uncomfortably full
Eating large amounts of food when not feeling physically hungry
Eating alone because of feeling embarrassed by how much one is
eating
Feeling disgusted with oneself, depressed or very guilty afterward
BEHAV11_04_
Binge Eating Disorder: Management

Other characteristics
Binge eating occurs, at least once a week for 3 months
Binge eating not associated with recurrent use of inappropriate
compensatory behaviors
Treatment
CBT + nutritional support + psychotherapy
SSRIs or SNRIs
Topiramate found to reduce binge-eating episodes
BEHAV11_04_
Behavioral Medicine
Paraphilias and Paraphilic Disorders
BEHAV06_01_
Paraphilias and Paraphilic Disorders: DSM-V Update

The distinction between paraphilias and paraphilic disorders applies
to all atypical erotic interests
There is a distinction between the name of a paraphilia and a
paraphilic disorder
Example
Pedophilia (paraphilia) & pedophilic disorder (paraphilic disorder)
Addition of specifiers for in remission/ in a controlled environment
BEHAV12_01_
Paraphilias and Paraphilic Disorders: Overview
Voyeuristic disorder
Exhibitionistic disorder
Frotteuristic disorder
Sexual masochism disorder
Sexual sadism disorder
Pedophilic disorder
Fetishistic disorder
Transvestic disorder
BEHAV12_01_
Paraphilias and Paraphilic Disorders: Diagnosis

DSM-V diagnostic criteria is as follows
Criterion A specifies the qualitative nature of the paraphilia
Example: an erotic emphasis on children
Criterion B specifies the negative consequences of the paraphilia
Example: distress, impairment, or harm or risk of harm to others
Paraphilia: those who only meet criterion A
Paraphilic disorder: those who meet both criterion A and B
BEHAV12_01_
Paraphilias and Paraphilic Disorders:

Characteristics
6 month period of recurrent, intense, sexually arousing fantasies
or sexual urges involving a specific act
The act is commonly followed by arousal and orgasm, usually
achieved by masturbation and fantasy
Differential Diagnosis
Alcoholism/substance abuse, depression/bipolar disorder,
intellectual developmental disorder, obsessive-compulsive disorder,
personality disorders, schizophrenia
BEHAV12_01_
Pedophilia, Exhibitionism and Voyeurism

Pedophilia/pedophilic disorder
Sexual urges toward children; most common sexual assault
Exhibitionism/exhibitionistic disorder
Recurrent desire to expose genitals to strangers
Voyeurism/voyeuristic disorder
Sexual pleasure from watching others who are naked, grooming, or
having sex; begins early in childhood
BEHAV12_01_
Sadism and Masochism

Sadism/sexual sadism disorder
Sexual pleasure derived from others pain
Masochism/sexual masochism disorder
Sexual pleasure derived from being abused or dominated
BEHAV12_01_
Fetishism and Frotteurism

Fetishism/fetishistic disorder
Sexual focus on objects
DSM-V update
Variant: transvestite fetishism, now transvestic disorder
Can be applied to women and gay men
Frotteurism/frotteuristic disorder
Male rubbing of genitals against fully clothed woman to achieve
orgasm
BEHAV12_01_
Zoophilia, Coprophilia and Urophilia

Zoophilia
Animals preferred in sexual fantasies or practices
Coprophilia
Combining sex and defecation
Urophilia
Combining sex and urination
BEHAV12_01_
Necrophilia and Hypoxyphilia

Necrophilia
Preferring sex with cadavers
Hypoxyphilia
Altered state of consciousness secondary to hypoxia while
experiencing orgasm
Variants: autoerotic asphyxiation, poppers, amyl nitrate, nitric oxide
BEHAV12_01_ 10
Paraphilias: Management
Cognitive behavioral therapy and other forms of psychotherapy
Sex education and therapy
Social skills and training
Medications
Goal is to decrease aggression and treat underlying illness
Examples: fluoxetine, lithium, mirtazapine, antipsychotics
BEHAV12_01_ 11
Behavioral Medicine
Gender Identity and Sexual
Preference
Gender Identity and Sexual Preferences

Gender Identity & Preferred Sexual Partner of Biological Male
BEHAV12_02_
Common Label
Gender Identity
Preferred Sexual Partner
Heterosexual
Male
Female
Transvestite
Male
Female
Transsexual
Female
Male
Homosexual
Male
Male
Behavioral Medicine
Gender Dysphoria
Gender Dysphoria
Formerly known as gender identity disorder
Diagnosis based on marked difference between the individuals
expressed/experienced gender and the gender others would assign him or
her, for a period of 6 months
Clinically significant distress or impairment in social, occupational, or other
important areas of functioning
DSM-V adds a post-transition specifier to ensure access to hormone
therapy, surgeries and psychotherapy
BEHAV12_03_
Behavioral Medicine
Sexual Disorders
Disorders of Sexual Desire

Hypoactive
Deficiency or absence of fantasies or desires
20% of population
More common in women
Treatment: psychosexual therapy
Sexual aversion
Aversion to all sexual contact
BEHAV12_04_
Sexual Arousal Disorders

Female sexual arousal disorder
33% of females (sometimes hormonally related)
Antihistamine and anticholinergic medications vaginal lubrication
Male erectile disorder (impotence)
Primary: never able to achieve erection
Secondary: once able to achieve erection
50% of men treated for sexual disorders
Treatment: PDE5 inhibitors, prostaglandin analogs, devices, psychosexual
therapy
BEHAV12_04_
Orgasm Disorders
Anorgasmia (inhibited female orgasm)
Likelihood to have orgasm with age
Inhibited male orgasm (retarded ejaculation)
Usually restricted to inability to orgasm in the vagina
Differentiate from retrograde ejaculation
Premature ejaculation
Male regularly ejaculates before or immediately after entering vagina
Treatments: stop and go technique, squeeze technique, SSRIs
BEHAV12_04_
Sexual Pain Disorders

Dyspareunia
Recurrent and persistent pain before, during, or after intercourse in
either man or woman
Chronic pelvic pain is a common complaint of women raped or
sexually abused
Vaginismus
Involuntary muscle constriction of the outer third of the vagina
Prevents penile insertion
Treatment: relaxation, Hegar dilators
BEHAV12_04_
Behavioral Medicine
Substance Use Disorder
BEHAV13_01_
Substance Abuse: DSM-V Update

Substance abuse: removed in DSM-V
Maladaptive pattern of drug use leading to clinically significant
impairment or distress in 12-month period
Failure to fulfill major job responsibilities at work, school, or
home
Recurring drug use in hazardous situations
Substance-related legal problems: removed in DSM-V
Social and interpersonal difficulties produced by or worsened by
substance use
BEHAV13_01_
Substance Dependence: DSM-V Update

Substance dependence: removed in DSM-V
Defined as 3 of the following within a 12-month period
Tolerance
Withdrawal symptoms
Use of substance in larger amount and for lengthier period than intended
Persistent desire/repeated unsuccessful attempts to stop
Much time/activity to obtain/use substance and to recover from its effects
Significant occupational, social, or recreational activities given up or
decreased
Use of substance continues despite knowledge of adverse consequences
BEHAV13_01_

Substance abuse/substance dependence combined into substance
use disorders
Disorder severity ranges from mild to severe and is based on the
number of criteria endorsed from a list of 11 different criteria
2 - 3 symptoms indicate a mild substance use disorder
4 - 5 symptoms indicate a moderate substance use disorder
6 symptoms indicate a severe substance use disorder
BEHAV13_01_
Substance Use Disorder: Diagnostic Criteria

DSM-V, Substance Use Disorders
Taking the substance in larger amounts or for longer

than meant to
Wanting to decrease the amount or D/C using the
substance but not managing to
Spending a lot of time getting, using, or recovering
from use of the substance
Cravings and urges to use the substance
Not managing to do what you should at work, home or
school, because of use
Continuing to use, even when it causes problems in
relationships
BEHAV13_01_
Giving up important social, occupational or other

activities because of use
Continually using the substance despite danger or
negative consequences
Continuing to use, even when aware that a physical or
psychological problem could have been caused or
made worse by the substance
Needing more of the substance to attain desired effect
(tolerance)
Development of withdrawal SX, which can be reversed
by taking the substance
Behavioral Medicine
Alcohol Use Disorder
Alcohol Use Disorder: Overview

Chronic, relapsing disorder that results from a variety of genetic,
psychosocial, and environmental factors
Characterized by physiologic/physical dependence and tolerance as
well as symptoms of withdrawal when consumption is interrupted
BEHAV13_02_
Alcohol Use Disorder: Complications

Hepatic: liver disease, hepatic steatosis, cirrhosis, hepatic failure,
hepatic encephalopathy
Wernicke-Korsakoff syndrome
Mallory Weiss syndrome
Delirium tremens
Other: acute/chronic pancreatitis, Wernicke encephalopathy,
alcoholic ketoacidosis, seizures
BEHAV13_02_
Alcohol Use Disorder: Management
Disulfiram: inhibits alcohol dehydrogenase

Acamprosate: helps prevent relapse
Benzodiazepines: prevent alcohol-related seizures
Naltrexone: opioid receptor antagonist, decreases alcohol craving
Supportive care
Alcoholics anonymous
BEHAV13_02_
Behavioral Medicine
Opioid Use Disorder
Opioid Use Disorder: Overview

Examples
Heroin, morphine, oxycodone
Mechanism of action
Stimulate , , receptors
receptor most important in a substance use disorder
Desired and undesired effects
Euphoria, analgesia, sedation, cough suppression, miosis,
constipation
BEHAV13_03_
Opioid Use Disorder: Management

Toxicity
Respiratory depression, nausea/vomiting, miosis, sedation, coma,
death
Treatment: naloxone, naltrexone
Withdrawal
Gooseflesh (cold turkey), diarrhea, rhinorrhea, lacrimation,
sweating, yawning, muscle jerks
Treatment
Methadone, buprenorphine, clonidine
BEHAV13_03_
Behavioral Medicine
Sedative, Hypnotic or Anxiolytic Use
Disorder
Sedative, Hypnotic, or Anxiolytic Use Disorder:

Overview
Benzodiazepines and barbiturates
BZs: alprazolam, lorazepam, temazepam, diazepam
Barbs: phenobarbital, pentobarbital
Mechanism of Action
BZs: frequency of GABAA channel opening
Barbs: duration of GABAA channel opening
BEHAV13_04_

Complications
CNS depression, drowsiness, alcohol-like drunken state (barbs)
Toxicity
Impaired judgment, slurred speech, incoordination, unsteady gait,
stupor, respiratory depression, death
BZ toxicity treatment: flumazenil
BEHAV13_04_

Management
Withdrawal
Anxiety
Delirium
Insomnia
Possible life-threatening seizures
Treatment
Long-acting benzodiazepine to suppress acute symptoms, taper
dose
BEHAV13_04_
Behavioral Medicine
Stimulant Use Disorder
Stimulant Use Disorder: Overview

Amphetamines and cocaine
Amphetamines: amphetamine salts, methylphenidate,
methamphetamine
Cocaine and crack
Mechanism of Action
Amphetamines: release DA, NE, 5HT, weak MAO inhibitor
Cocaine: blocks DA, NE, 5HT reuptake
BEHAV13_05_
Stimulant Use Disorder: Complications

Euphoria, hypervigilance, anxiety
Stereotyped behavior, grandiosity
Tachycardia, pupillary dilation, appetite
Toxicity
Cardiac arrhythmias, myocardial infarction, stroke
Hallucinations, paranoia, hyperthermia
Seizures, death
BEHAV13_05_
Stimulant Use Disorder: Management

Toxicity treatment
Benzodiazepines, neuroleptics
Control hyperthermia and CV effects
Supportive care
Withdrawal
Craving, depression, fatigue
sleep time, appetite
BEHAV13_05_
Behavioral Medicine
Other Hallucinogen Use Disorder
Other Hallucinogen Use Disorder

Examples: LSD, mescaline, psilocybin
Mechanism of action: interacts with 5HT receptors
Perceptual changes, synesthesias, nausea
Toxicity
Panic reaction (bad trip) possible, flashbacks
Withdrawal
Minimal because of lack of physiologic dependence
BEHAV13_06_
Behavioral Medicine
Cannabis Use Disorder
Cannabis Use Disorder

Mechanism of action: binds CB1 and CB2 cannabinoid receptors
Euphoria, disinhibition, perceptual changes, reddened conjunctiva, dry
mouth, appetite, antiemetic effects
Toxicity
Amotivational syndrome, respiratory effects
Withdrawal
Mild irritability/anxiety
BEHAV13_07_
Behavioral Medicine
Phencyclidine Use Disorder
Phencyclidine Use Disorder
Assaultive, combative and impulsive behavior

Agitation
Nystagmus, ataxia, muscle rigidity
response to pain
Hyperacusis, paranoia
Unpredictable violence, psychosis, hypertension
Life-threatening seizures
Ketamine is a congener of PCP (might also be abused)
BEHAV13_08_
Behavioral Medicine
Other (or Unknown) Substance Use
Disorder
Other (or Unknown) Substance Use Disorder

MDMA
5HT releasers (amphetamine-like mechanism, except releases more
5HT than dopamine)
May cause damage to serotonergic neurons, hyperthermia
Anticholinergics
Deliriant effects
Examples: Jimson weed, scopolamine
BEHAV13_09_
Behavioral Medicine
Tobacco Use Disorder
Tobacco Use Disorder

Examples: cigarettes, cigars, chewing tobacco
Associated with cardiovascular, respiratory, and neoplastic disease
Cessation
Nicotine patches and gum
Bupropion, varenicline, and bromocriptine
BEHAV13_10_
Behavioral Medicine
Inhalant Use Disorder
Inhalant Use Disorder

Examples
Glue, solvents
Effects
Belligerence, impaired judgment, incoordination
Causes multiple organ damage
BEHAV13_11_
Behavioral Medicine
Management
Substance Use Disorder: Management

Stages of change in overcoming a substance use disorder
Pre-contemplation: does not realize that there is a problem
Contemplation: realizes there is a problem but unwilling to correct
Determination: prepared to take necessary action
Action: act of taking necessary step to change behavior
Maintenance
Relapse
BEHAV13_12_
Behavioral Medicine
Physicians Ethics
BEHAV14_01_
Physicians Ethics
Beneficence
Physicians have an ethical duty to always act in the
best interest of their patients
May conflict with patient autonomy
However, if the patient is competent to make an informed decision,
the patient has the ultimate right to decide
BEHAV14_01_
Physicians Ethics
Non-maleficence
Do no harm (latin: primum non nocere)
Never intentionally inflict harm on a patient
If the benefits of a treatment/procedure outweigh the risk, a patient
can make an informed decision to undergo the treatment or
procedure
Examples
Surgery, medication with severe side effects
BEHAV14_01_
Physicians Ethics
Justice
Treat all patients fairly and equally
A physician should not let their personal feelings affect the way a patient
is treated
Patient Autonomy
Obligation to respect the wishes of an informed and competent patient
as well as honor their individual preferences in medical care
The patient ultimately decides what treatments / procedures they will or
will not receive
BEHAV14_01_
Behavioral Medicine
Informed Consent
Informed Consent
Informed consent
Risks/benefits/alternatives
Alternative includes: do nothing
Full, informed consent requires that patient receive and understand:

1. Nature of procedure (what)
2. Purpose or rationale (why)
3. Risks
4. Benefits
5. Alternatives
BEHAV14_02_
Exceptions to Informed Consent
Four exceptions to informed consent:

1. Emergency
2. Waiver by patient
3. Patient is incompetent
4. Therapeutic privilege (unconscious, confused, physician
deprives patient of autonomy in interest of health)
BEHAV14_02_
Key Points for Informed Consent

Consent can be oral
A signed paper the patient has not read or does not understand
does not constitute informed consent
Written consent can be revoked orally at any time
BEHAV14_02_
Behavioral Medicine
Ethics Concerning Minors
Emancipated Minors
Children < 18 years are minors and legally incompetent
Exceptions: emancipated minors
If > 13 years and taking care of self, i.e., living alone, treat as an
adult
Marriage makes a child emancipated, as does serving in the
military
Pregnancy or giving birth, in most cases, does not
BEHAV14_03_
Special Cases for Minor Competency

Partial emancipation
Many states have special ages of consent
Parental consent not necessary for certain issues
Emergency situations
Substance drug treatment
Prenatal care
Sexually transmitted disease treatment
Birth control
BEHAV14_03_
Behavioral Medicine
Patient Confidentiality
Patient Confidentiality & Patient

Decisions
Physicians cannot tell anyone anything about their patient without
the patients permission
Physician must strive to ensure that others cannot access patient
information
Getting a consultation is permitted, as the consultant is bound by
confidentiality, too. However, watch the location of the consultation.
Be careful not to be overheard (e.g., do not discuss in elevator or
cafeteria)
If you receive a court subpoena, show up in court but do not divulge
information about your patient
BEHAV14_04_
Physicians Duty to Warn and Protect

Physicians cannot tell anyone anything about their patient without
the patients permission
If patient is a threat to self or other, the physician MUST break
confidentiality
Duty to warn and duty to protect (Tarasoff case) + driving (DWI)
A specific threat to a specific person (including self)
Tarasoff decision: duty to warn and duty to protect
BEHAV14_04_
Behavioral Medicine
Decision-Making Capacity
Decision-Making Capacity
Essential components
The patient makes and communicates a healthcare-related choice
The patient knows and understands what is about to happen (patient
is informed)
The decision remains stable over time
The decision is consistent with the patients normal core values and
goals (not affected by a mood disorder)
The decision is not occurring as a result of a psychiatric disorder
(delusion, hallucination, etc)
BEHAV14_05_
Decision-Making Capacity II
The patient must be fully informed about all issues related to a
procedure or treatment
A family member cannot require the physician to withhold
information
BEHAV14_05_
Behavioral Medicine
Surrogate Decisions
Surrogate Decisions
In order for a surrogate to make a decision three things must occur:

The patient is incapacitated
The patient has not made an advance directive
An individual (surrogate) who knows what the patient would truly
want if they were competent is identified
BEHAV14_06_
Priority of Surrogates
Spouse
Adult children
Parents
Adult siblings
Other relatives
BEHAV14_06_
Behavioral Medicine
Advance Directives
Advance Directives: Overview
Instructions that are given by a patient in anticipation of the need for

a medical decision in the event that the patient becomes
incompetent:
Oral advance directive

Statements made by a patient prior to incapacitation
BEHAV14_07_
Other Advance Directives

Living Will
Written advance directive
Describes treatment measures that the patient wants if she/he loses
decision-making capacity
Medical power of attorney
Designated agent assigned by the patient to make medical
decisions in the event she/he loses decision-making capacity
BEHAV14_07_
Behavioral Medicine
Malpractice
Malpractice
Malpractice
Civil, not criminal
Components of Malpractice
Duty
Breach (dereliction)
Harm done (damage)
Breach caused the harm (direct)
BEHAV14_08_
Behavioral Medicine
Ethical and Legal Issues
Situational Testing: Overview

Situational Testing
1 right answer; many misleading answers
Choose BEST
Dating
Family wants info
Child wants to know more
Child pregnant, wants abortion
BEHAV14_09_
Situational Testing
Choose BEST
Child pregnant, wants to keep but parents want adoption
Physician-assisted suicide = no go
Pharmaceutical company bonus = no go, but still use the
company
Unnecessary procedures: delve deeper, dont refer away
BEHAV14_09_
Ethical and Legal Issues

General rules that a competent physician should follow
to maintain good ethical standards and avoid possible
legal issues
Good guide to follow for the USMLE as well as when you
are a practicing physician
Remember to always choose the BEST answer
BEHAV14_09_
Ethical and Legal Issues: Rule 1

Competent patients have the right to refuse medical
treatment OR a part of that treatment
BEHAV14_09_

Always assume that the patient is competent unless there is clear
behavioral evidence that indicates otherwise
Competence is a legal not a medical issue. Clear behavioral
evidence that suggests incompetence includes:
Suicide attempt
Grossly psychotic and dysfunctional behavior
The patients physical or mental state prevents simple
communication
BEHAV14_09_
Ethical and Legal Issues: Rules 3 & 4

Rule #3
Avoid going to court. Decision-making should occur in the clinical
setting if possible
Rule #4
When surrogates make decisions for a patient, they should use the
following criteria and in this order:
1. Subjective standard
2. Substituted judgment
3. Best interests standard
BEHAV14_09_

If the patient is incompetent, the physician may rely on
advance directives
Advance directives can be oral or written (living will)
HCPOA is a patient designated surrogate decision
maker that speaks with the patients voice
BEHAV14_09_

Rule #6
A feeding tube is a medical treatment and can be withdrawn at the
patients request
Rule #7
Do nothing to actively assist the patient to die sooner
Allowing a patient to die passively is OK but the physician cannot
provide the means to end life
BEHAV14_09_

Rule #8
The physician decides when the patient is dead
Only a judge can declare death
Rule #9
Never abandon a patient
Annoying or difficult patients are still your patients
Lack of financial resources or treatment results is never a reason to
stop treatment
BEHAV14_09_ 10
Keep the physician-patient relationship within bounds

Do not date your patients or their family members
Do not treat your family or friends
Do not prescribe for colleagues unless a
physician/patient relationship exists
If a patient acts inappropriately, you can explain to them
about appropriate behavior
Gifts should be declined
BEHAV14_09_ 11
Stop harm from happening

Prevent a patient from harming themselves or others
May require a breach of patient confidentiality
Examples of harm include reportable diseases, Tarasoff
Decision related cases, child/elder abuse, impaired
automobile drivers or suicidal/homicidal patients
BEHAV14_09_ 12

Always obtain informed consent
Full, informed consent requires that the patient has
received and understood five pieces of information:
BEHAV14_09_ 13
Nature of the procedure

Purpose or rationale
Risks of the treatment regimen
Benefits of the treatment regimen
Alternatives to the recommended treatment regimen
Ethical and Legal Issues: Rule 12b

Exceptions to informed consent
Emergency situation
Waiver by the patient
Incompetence
Therapeutic privilege
BEHAV14_09_ 14

Special rules apply with children
Children younger than 18 years are minors and are legally
incompetent
Exceptions: emancipated minors
If patient is older than 13 years and taking care of self, i.e., living alone,
treat as an adult
Marriage makes a child emancipated, as does serving in the military
Pregnancy or having a child, in most cases, does not
BEHAV14_09_ 15

Partial emancipation
Consent not needed for certain issues only
Substance drug treatment
Prenatal care
Sexually transmitted disease treatment
Birth control
BEHAV14_09_ 16

Parents cannot withhold life or limb-saving treatment from their
children
Rules below should be followed if parents refuse permission to treat
1. If immediate emergency, go ahead and treat
2. If not immediate, but still critical, generally the child is declared
a ward of the court and the court grants permission
3. If not life- or limb-threatening (i.e. need for minor stitches),
listen to the parents
BEHAV14_09_ 17

Organ donation usually requires patients and family
consent
BEHAV14_09_ 18

Good Samaritan laws limit liability in nonmedical settings
Physician is NOT required to stop and help
If physician stops to help liability is limited as long as certain rules
are followed:
Actions are within physicians competence
Only accepted procedures are performed
Physician remains at scene after starting therapy until relieved
by competent personnel
No compensation changes hands
BEHAV14_09_ 19

Patient confidentiality is (almost always) absolute
Physicians cannot tell any person not directly involved
with the care of a patient anything about their personal
health information without the patients permission
BEHAV14_09_ 20

Exceptions to confidentiality include:
Duty to warn and to protect (Tarasoff case)

A specific threat to a specific person
Suicide, homicide, and child and elder abuse are obvious threats
Infectious diseases may need to be reported to public officials or
an innocent third party
Impaired drivers
BEHAV14_09_ 21

Patients should be given the chance to state DNR (do
not resuscitate) orders, and physicians should follow
them
DNR only refers to cardiopulmonary resuscitation
BEHAV14_09_ 22

Committed mentally ill patients retain their rights, which
includes treatment and ability to refuse treatment
They only lose their civil liberty of coming and going from
the institution
BEHAV14_09_ 23

Detain patients to protect them or others
If a patient is determined to be a danger to themselves
or other, a physician (or law enforcement official) can
detain a patient for up to 48-hours pending a hearing
A physician can detain AND only a judge can commit
BEHAV14_09_ 24

Remove from patient contact health care professionals
who pose risk to patients
If a healthcare profession poses a danger to patients
they must be immediately removed from their duties to
prevent patient harm
Examples include substance abuse, depression or other
appropriate psychiatric disorders, incompetence, and
selected infectious diseases
BEHAV14_09_ 25

Focus on what is the best ethical conduct, not simply the
letter of the law
The best conduct is both legal and ethical
BEHAV14_09_ 26

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Behavioral Medicine

Birth Weight and APGAR Score

APGAR Scoring System

Irregular, shallow gasps

Pale, blue extremities

Reflex irritability None

Physical and Motor

Puts everything in mouth

Development Milestones: Year 1

Physical and Motor

Development Milestones: Year 2

Physical and Motor

Selfish and selfcentered

Development Milestones: Year 3

Physical and Motor

Development Milestones: Year 4

Physical and Motor

Can tell stories

Development Milestones: Year 5

Physical and Motor

Asks the meaning of

Development Milestones: Years 6 - 12

Physical and Motor

Abstracts from objects

Development Milestones: Years 12

Physical and Motor

Female and Male Pubic Hair

Sparse, long straight

Darker, curling, increased

Penis grows in length; testes

Course, curly, adult type

Penis grows in length/breadth,

Adult; extends to thighs

Pharmacokinetic Changes in the Elderly: GI

A slowing of GI transit can

prolong the time until orally

Pharmacokinetic Changes in the Elderly: Distribution

Physiological Age-Related Changes

Pharmacokinetic Changes in the Elderly: Liver

Physiological Age-Related Changes

Hepatic metabolism Overall drug-metabolism via

Pharmacokinetic Changes in the Elderly:

Physiological Age-Related Changes

Glomerular filtration rate decreases

Chronic kidney disease

Grief Vs. Depression

Can last longer than 1 year

Crying, decreased libido, weight loss, insomnia

Crying, decreased libido, weight loss, insomnia

Longing, wish to see loved one, may think they

Abnormal overidentification, personality change

Suicidal ideation rare

Suicidal ideation common

Self-limited, usually < 6 months

Symptoms do not stop (may persist for years)

Antidepressants not indicated (unless MDD is

Circadian Rhythm and Sleep

N1: light sleep theta waves

Night Terrors vs. Nightmares

Stage 4 (delta sleep)

Recall upon waking

Waking time anxiety

Yes, usually unidentified