Behavioral Notes DSM 5

7/26/2019 Behavioral Notes DSM 5

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Legal Ethics

If a patient is legally dead (brain dead), the physician is authorized to remove life support without acourt order or consent from family

If a competent patient requests cessation of articial life support, it is both legal and ethical for aphysician to comply with this request

If the physician believes that the patient's health will be adversely aected by the news of amalignancy, he or she can delay telling the patient the diagnosis until he or she is ready toreceive the biopsy report

patient (e!g!, the father) who is legally competent can refuse lifesaving treatment for himself forreligious or other reasons, even if death will be the outcome! "owever, a parent (or guardian)cannot refuse lifesaving treatment for hischild for any reason

A pregnant woman has the right to refuse medical tests or treatment even if the fetus willdieor be seriously in#ured as a result! fter the child is born, the mother cannot refuse to have ittested or treated for HIV

$ompetent pregnant women, li%e all competent adults, can refuse medical treatment, even if the fetuswill die as a result

&he priority order in which family members ma%e this determination is the ) spouse, ) adult children,) parents, *) siblings, and +) other relatives

With respect to the paternity nding the physician should neither write it in the chart nortell the couple! It is not appropriate for physicians to divulge information obtained serendipitously inthe course of genetic testing and unrelated to the purpose of the testing

&his girl's parents should be advised not to test the girl for the fragile gene until she is an adult (atleast - years old) and requests the test! !enetic testing for carrier status should be deferreduntil either the child reaches maturity" or the child needs to ma#e reproductive decisions$.

&he rst/year resident should as% the attending surgeon to get consent from the patient himself!$onsent cannot be obtained until the patient has been informed and understands the health

implications of her diagnoses, health ris%s and benets of treatment, the alternatives to treatment,li%ely outcome if she does not consent to the treatment and that she can withdraw consent fortreatment at any time!

%arents can refuse e&perimental treatment of their child for any reason$

If patient cannot communicate and there is no written instructions ne0t of %in becomes responsible formedical decisions

1234 no intubation or mechanical ventilation, no chest compression, no debrillation

5ou can give emergency blood transfusion to preserve life of incompetent 6ehovas witness when thereis no blood refusal card"no other appropriate treatment options available and communicationwith the patients surrogate is inade'uate

In nonemergent cases call an interpreter when there is language barrier involving a patient

7atients have the right to refuse to receive medical information! 7hysicians must also understand andrespect beliefs of cultures that value benecence over autonomy! In these cultures family membersmay be e&pected to ma#e medical decisions to avoid perceived harm" disrespect or mentaldistress caused by direct disclosure to the patient

In an emergency situation physician can share patients medical information when it is in the patientsbest interest based on their professional #udgement


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ont prescribe antibiotics if it is not bacterial even if patient demands it because ofwidespread antibiotic resistance and adverse reactions to antibiotic therapy

7hysician can %eep pregnancy condential but should encourage teenager to see% help from herparents

%regnancy through %reschool

*hildren under the age of + years do not understand the nality of deathand fully e0pectdead people to come bac% to life! It is not until about age , that children begin to understandthat they can also die

8oud protests occur initially when the mother leaves the child! 9ith her continued absence this childe0periences other serious reactions including depression, decreased responsiveness to adults, anddecits in the development of social and motor s%ills

- year.oldchildren such as this one should have a vocabulary of about ,// wordsand spea% incomplete sentences

7ostpartum depression occurs in +:;. is an importantquestion since a predictor of postpartum reactions is whether or not they have occurred before!&his patient is probably worried because she has had previous problems

It is normal for a /year/old child to have di=culty sitting still for any length of time! ?y school age,children should be able to sit still and pay attention for longer periods of time

&ransferring ob#ects from hand to hand commonly occurs at about < months of age!Infants can usually turn over at about + months of age!$hildren begin to show social smiling between 0 and 1 months of age!$hildren begin to respond to their own names between @ and months of age!$hildren begin to use a utensil to feed themselves at about years of age

2chool Age" Adolescence and adulthood

7arents should be present when a physician spea%s to a younger child but teenagers usually should beinterviewed, particularly about se0ual issues, without parents present

&he best time to tell a child she is adopted is as soon as possible, usually when the child can rstunderstand language

&eenagers who become pregnant frequently are depressed, come from homes where the parents aredivorced, have problems in school, and may not %now about eective contraceptive methods!

9hile midlife is associated with the possession of power and authority, physical abilities decline! &histime of life is also associated with a midlife crisis, which may include increased alcohol and drug use aswell as an increased li%elihood of change s in social and wor% relationships!

&anner stages40$ Aenitalia and associated structures are the same as in childhoodB nipples (papillae) are slightly

elevated in girls! 7ubic hair consists of ne villus hair! &urner syndrome1$ Ccant, straight pubic hair, testes enlarge, scrotum develops te0tureB slight elevation of

breast tissue in girls-$ 7ubic hair increases over the pubis and becomes curly, penis increases in length and testes

enlarge3$ 7enis increases in width, glans develops, scrotal s#in dar#ensB areola rises above the rest

of the breastin girls


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4$ Dale and female genitalia are li%e adultB pubic hair now is also on thighs, areola is no longerelevated above the breast in girls

&he formation of a personal identity is usually achieved during the teenage years&he concepts of seriation and conservation and an understanding of the concept of .fair play. aregained during the school/age years

8eading %iller of frican merican men between ages of +/* is unintended in#ury (accidents)!?etween +/* / homicide

!enetics" Anatomy and 5iochemistry of 5ehavior

7lacebo response is based in part on activation of the endogenous opioid system

n0iety, abdominal cramps and diarrhea, and s%in Eushing are symptoms of pheochromocytoma ; 2Fsecreting adrenal tumor

&he corpus callosum and the hippocampal, habenular, and anterior commissures connect the twohemispheres of the brain!

"istamine receptor bloc%ade with drugs such as antipsychotics and tricyclic antidepressants isassociated with common side eects of these drugs such as sedation and increased appetiteleading to weight gain

Alutamate contributes to the pathophysiology of disorders such as schi6ophrenia" Al6heimerdisease" and other neurodegenerative illnesses$7emantine a bloc%er of the 2/methyl/d/aspartate (2D1) receptor, a type of glutamate receptor, hasbeen approved to treat lzheimer disease and may prove useful also in the treatment of schizophrenia

8E is metaboli6ed to 7H%!

GlHver/?ucy syndrome, which includes hyperse0uality and docility and is associated with damage tothe amygdala

Cleep/arousal mechanisms are aected by damage to the reticular system

?rains of patients with schizophrenia are li%ely to show decreased volume of limbic structuressuch as the hippocampusB increased si6e of cerebral ventriclesdue, in part, to brain shrin%ageBand decreased glucose utili6ation in the frontal corte&

epressionis most li%ely to be associated with damage to the left frontal lobe

ssaultive, impulsive, aggressive behavior is associated with decreased levels of serotonin in thebrain! 8evels of +/"I (+/hydro0yindoleacetic acid), the ma#or metabolite of serotonin, have beenshown to be decreased in the body Euids of violent, aggressive, impulsive individuals as well asdepressed individuals! 7H%! (-.metho&y.3. hydro&yphenylglycol)" a metabolite ofnorepinephrine" is decreased in severe depression

?ehavioral changes such as decreased impulse control, poor social behavior, and lac% of characteristic

modesty indicate that the area of the brain most li%ely to have been in#ured in this patient is theorbitofrontal corte0! 8esions of this brain area result in disinhibition, inappropriate behavior, and poor#udgment! In contrast, lesions of the dorsolateral conve0ity of the frontal lobe result in decreasede0ecutive functioning (e!g!, motivation, concentration, and attention)

2ucleus ceruleus ; 2F, dorsal pons3aphe nuclei of brainstem ; serotonin2ucleus basalis of Deynert ; cell bodies of cholinergic neurons

5iological Assessment of %atients with %sychiatric 2ymptoms


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&he ?ender isual Dotor Aestalt &est is used to evaluate visual and motor ability by reproduction ofdesigns! &he 8uria/2ebras%a neuropsychological battery is used to determine cerebral dominance andto identify specic types of brain dysfunction, while the "alstead/3eitan battery is used to detect andlocalize brain lesions and determine their eects

Intravenous administration of sodium lactatecan help identify individuals with panic disordersince

it can provo%e a panic attac% in such patients

7ositron emission tomography (7F&) localizes physiologically active brain areas by measuring glucosemetabolism! &hus, this test can be used to determine which brain area is being used during a specictas% (e!g!, translating a passage written in Cpanish)

Fvo%ed FFAs measure electrical activity in the corte0 in response to sensory stimulation

&he amobarbital sodium (mytal) interview is used to determine whether psychological factors areresponsible for symptoms in this patient who shows a non/medically e0plained loss of sensory function(conversion disorder)

$omputed tomography ($&) identies organically based brain changes, such as enlarged ventricles!&hus, although not diagnostic, this test can be used to identify anatomical changes in the brain, suchas enlarged ventricles in a patient with suspected dementia of the lzheimer type

7oor appetite, poor sleep, and lac% of interest in normal activities characterize patients who havema#or depression! In this depressed woman, the de&amethasone suppression test is li#ely to bepositive$ A positive result is seen when the synthetic glucocorticoid de&amethasone fails tosuppress the secretion of cortisol as it would in a normal patient$lso, in depression theremay be abnormal growth hormone regulation and melatonin levels, and decreased +/"I

"yperthyroidism is more commonly associated with the symptoms of an0iety!

Ccores below < on the Jolstein Dini/Dental Ctate F0amination indicate signicant cognitiveimpairment! &his test does not evaluate calculating ability or IK! lthough the patient is impaired, it isnot clear what caused the problem or whether she needs to be placed in an assisted living facility

%sychoanalytic 9heory and efense 7echanisms

In Jreud's structural theory, the mind is divided into the id" ego" and superego$&he id operatescompletely on an unconscious level, while the ego and superego operate partly on an unconscious andpartly on preconscious and conscious levels! Id is present at birth ; instinctive se0ual and aggressivedrives not inEuenced by e0ternal reality! Fgo develops after birth ; controls e0pression of Id by the useof defense mechanisms and reality testing! Cuperego begins to develop at L years and is associatedwith morals and conscience!

Cublimation, e0pressing an unacceptable emotion in a socially acceptable way, is classied as amature defense mechanism! 1enial, dissociation, regression, and intellectualization are all classied asless mature defense mechanisms

7rimary process thin%ing is associated with pleasure see%ing, disregards logic and reality, has noconcept of time, and is not accessible to the conscious mind! Cecondary process thin%ing is logical andis associated with reality!

Demory of the details of the Grebs cycle, while no longer in the forefront of the medical student's mind,can be recalled relatively easily wee% after the e0amination! &his memory therefore resides in thepreconscious mind! &he unconscious mind contains repressed thoughts and feelings, which are notavailable to the conscious mind! &he conscious mind contains thoughts that a person is currentlyaware of

Jantasy ; immature defense mechanism that substitutes an imaginary less disturbing view of the worldto avoid awareness of painful feelings


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Learning 9heory

Habituation; continued e0posure to a stimulus (the re alarm, in this e0ample) results in adecreased response to the stimulus$&hus, while the students respond quic%ly to the re alarm atrst, with repeated soundings of the alarm, they ultimately fail to respond to it! If sensiti6ation hadoccurred" the students would have responded more 'uic#ly with each e&posure to thealarm

&he cerebellum participates in classical conditioning, specically in associations involving motors%ills!

&he unconditioned response is reEe0ive and automatic and does not have to be learned! &heunconditioned stimulus (pizza) is the only element here that by itself will elicit a natural AI reEe0(stomach growling)

?y classical conditioning, the animal learns that there is an association between an aversive stimulus(e!g!, painful electric shoc%) and the inability to escape! Cubsequently, the animal ma%es no attempt toescape when shoc%ed or when faced with any new aversive stimulusB instead, the animal becomeshopelessand apathetic$8earned helplessness in animals may be a model system for depression(often characterized by hopelessness and apathy) in humans!

In stimulus generali6ation" a new stimulus (e!g!, a church bell) that resembles a conditioned

stimulus (e!g!, the lunch bell) causes a conditioned response (e!g!, salivation)

2haping involves rewarding closer and closer appro0imations of the wanted behavior until the correctbehavior is achieved (e!g!, a child learning to write is praised when she ma%es a letter, even though itis not formed perfectly)&ips for behavioral modication

/ s%ing patients to ma%e big changes is often not successful/ better approach is to brea% down changes into increments and use a step by step approach

(shaping) to gradually change behavior

7odeling is a type of observational learning (e!g!, an individual behaves in a manner similar to that ofsomeone she admires)

Assessment of %atients with 5ehavioral %roblems

2ormal intellectual function (IK M


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mphetamines li%e .speed. reduce appetiteB use can thus result in decreased body weight!mphetamines also decrease fatigue, increase pain threshold, and increase libido

"eroin users show an elevated, rela0ed mood and somnolence

9ithdrawal from benzodiazepines is associated with tremor, insomnia, and an0iety! 9ithdrawal frombarbiturates can cause the same and also seizures

Da#or mechanism of action of cocaine is to bloc% reupta%e of dopamine

&he presence of "I as well as signs of sedation and euphoria indicate that this patient is anintravenous heroin user

iolence and subsequent trauma are most common causes of death in 7$7 use

8ormal 2leep and 2leep isorders

Cedative agents have a high abuse potential and because they tend to reduce 3FD and delta sleep,their use may result in sleep of poorer quality

&heta waves are primarily seen in stage sleep!

In young adults, *+: of total sleep time is spent in stage sleep! Jive percent is spent in stage , +:in 3FD, and +: in delta sleep!

Cleep in ma#or depression is associated with increased 3FD sleep, reduced delta sleep, and decreasedsleep latency

Cleep in elderly patients is characterized by increased stage and stage sleep, increased nighttimeawa%enings, decreased 3FD sleep, and much reduced or absent delta sleep

Gleine/8evin syndrome is usually seen in adolescents and involves recurrent periods of hypersomniaand hyperphagia, each lasting ; wee%s

t the end of the month, the length of this student's circadian cycle in the absence of cues from theoutside world is li%ely to be close to + hours! Ctudent slept in cave for one month with no access to

cloc%s or watches

2arcolepsy with cataple0y is most often caused by the lac% of neuropeptides hypocretin.0(ore0in )and hypocretin .1(ore0in ?) produced by neurons in the lateral hypothalamus! &hey promotewa%efulness

2chi6ophrenia and %sychotic isorders

In patients with schizophrenia, the size of cerebral ventricles, glucose utilization in the frontal lobes,and size of limbic structures are most li%ely to be increased" decreased" and decreased,respectively

Cchizoaective disorder is characterized by symptoms of a mood disorder, as well as psychoticsymptoms, and lifelong social and occupational impairment

1isorganized schizophrenia is characterized by disinhibition, poor grooming, poor personalappearance, and inappropriate emotional responses

%ositive symptoms such as delusions respond better to antipsychotic medication

8egative symptoms respond better to atypical antipsychotic medication than to traditionalantipsychotics

n illusion is a misperception of a real e&ternal stimulus(e!g!, a computer loo%ing li%e a lionlur%ing in the corner in a dar%ened room)! hallucination is a false sensory perception


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2europsychological evaluation of a patient with schizophrenia is most li%ely to reveal frontal lobedysfunction! 7eople with schizophrenia usually show intact memoryB orientation to person, place, andtimeB and normal intelligence

&he chance that the son (or other rst/degree relatives) of a person with schizophrenia will develop thedisorder over the course of his life is appro0imately 0/


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A1 / tingling in the e0tremities, often resulting from hyperventilation!

$onversion disorder ; sudden hemiparesis ; patient does not care abt it (la belle indierence)

*ognitive" %ersonality and Eating isorders

nore0ia is also characterized by family conEicts, particularly with the mother, normal appetite"high interest in food and coo#ing" low se&ual interest" good school performance" ande&cessive e&ercising

%seudodementia?depression that mimics dementia

?orderline personality disorder / typically use splitting (see $hapter L) as a defense mechanism! 2elf.in=urious behaviorand impulsive behavior (e!g!, drug abuse" se& with multiple partners)alsoare characteristic of people with this personality disorder

1issociative identity disorder (formerly multiple personality disorder)! Che does not remember the manwho signed the letter or posing for the photograph because these events occurred when she wasshowing another personality!

1issociative amnesia involves a failure to remember important information about oneself, anddissociative fugue is amnesia combined with sudden wandering from home and ta%ing on a dierentidentity

Histrionic personality disorder @ act rashly without thin#ing

%sychiatric isorders in *hildren

ett disorder . iminished social" verbal" and cognitive development after up to * years ofnormal functioning! Rccurrence only in girls (3ett disorder is /lin%ed and aected males die beforebirth)! Ctereotyped, hand.wringing movementsB ata0ia, ?reathing problems, Dental retardation,Dotor problems later in the illness

$hildren with oppositional deant disorder have problems dealing with authority gures but not with

other children or animals as in conduct disorder ; also stealing

Rbsessive/compulsive disorder (R$1) is particularly associated with &ourette disorder

%sychopharmacology

&ardive dys%inesia usually occurs after at least L months of starting a high/potency antipsychotic andis best treated by changing to a low.potency or atypical agentB stopping the antipsychoticmedication will e&acerbate the symptoms

2euroleptic malignant syndrome is seen most commonly with high/potency antipsychotic treatmentand is best relieved by stopping the antipsychotic medication" providing medical support" andadministering dantrolene, a muscle rela0ant! fter recovering from this life/threatening condition,the patient can be put on an atypical agent which is less li%ely to cause this dangerous side eect

F$& is a safe, fast, eective treatment for ma#or depression if other antidepressant medications are notwor%ing

typical agents, li%e clozapine are more eective against negative symptoms (e!g!, withdrawal) thantypical antipsychotics

Amo&apine ; drug used for ma#or depression! "as antidopaminergicactionand, thus, is the agentmost li%ely to cause gynecomastia as well as par%insonian symptoms in a patient!


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228Is may wor# more 'uic#ly than other antidepressants and, as such, venlafa&ine is agood choice for rapid relief of depressive symptoms

Imipramine, a tricyclic antidepressant, is most li%ely to cause Eattening of & waves and prolonged K&interval! 2ortriptyline is the least li%ely of the cyclic agents to cause these changes

1opamine normally suppresses acetylcholine activity, giving the patient an anticholinergic agent (e!g!,

benztropine) will serve to increase dopaminergic activity and relieve the patient's symptoms ; druginduced 7ar%inson symptoms

Cpioid analgesics now number 0 cause of overdose deaths in D2

%sychological 9herapies

Cystematic desensitization is based on classical conditioning! &he lm of people entering elevatorsin a high.rise building is paired with rela&ation

5iofeedbac# is based primarily on operant conditioning

3eciprocal inhibition is the mechanism that prevents one from feeling two opposing emotions at thesame time (e!g rela0ation and fear), and is associated with systematic desensitization

In aversive conditioning, classical conditioning is used to pair a maladaptive but pleasurable stimuluswith an aversive or painful stimulus

Implosion / person is instructed to imagine e0tensive e0posure to a feared stimulus

2e&uality

Jluo0etine and other selective serotonin reupta%e inhibitors (CC3Is) are more li%ely to cause delayed orabsent orgasm

%ropranolol (beta bloc#ers)" clonidine" methyldopa can cause erectile dysfunction

ging is also characterized by a longer refractory period and delayed e#aculation in men anddecreased intensity of orgasm in men and women

7atient's erectile problems are most li%ely to be associated with his alcohol drin%ing! *igarettesmo#ing is less li#ely than alcohol to aect se&ual function

7ost common cause of pelvic inFammatory disease (%I) in women is chlamydial infection

%hysician %atient elationship

Cbsessive.compulsive patients fear loss of control and may in turn become controlling(e$g$" having the physician wait while he ma#es a phone call) during illness

&here is no clear association between compliance and race, socioeconomic status, education, orgender

%sychosomatic 7edicine

$hronic pain patient is at high ris% for depression

?ecause of the disorienting nature of the I$S, delirium is commonly seen in I$S patients!

Health *are in the D2

Dedicare- 7art 4 Inpatient hospital care, home health care, medically necessary nursing/home care for a

limited time after hospitalization, hospice care


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- 7art ?4 7hysician fees, dialysis, physical therapy, laboratory tests, ambulance service, medicalequipment (7art ? is optional and has a

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Behavioral Notes DSM 5