Behavioural Science Defense mechanisims

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

Projection: your feelings onto someone else ( causes paranoia) Denial: act as if never happened ( first response to bad news, substance abusers) Splitting: EITHER GOOD OR BAD ( Borderline personality disorder, prejudice)

Blocking: temporary block in thinking Regression: go to more childish state ( new sibling born, starts peeing again and wants to be breast fed when weren’t before ) Somatization: psychological converted to bodily symptoms Identification/ introjection: take the actions of others and do to self ( teenager act like their fav rockstar) ( I will never act like my mother but they do)

Displacement : putting emotion on a more appropriate target Repression: idea eliminated from CONSIOUSNESS (forget and don’t remember it ever) UNCOSIOUSLY ( forget and not retrievable) Isolation of affect: don’t display any emotion Intellectualization: use intelligent words to remove emotions/ affectActing-out: act out strongly to cover up an emotionRationalization: look for a reason to justify action

Reaction Formation: unacceptable made into OPPOSITE Undoing: acting out to reverse unacceptable behavior (man cheats, buy wife flowers) Passive-Aggressive: Hostility Dissociation: separate self form experience ( extreme is dissociation disorder)

Humor: laughter covers pain Sublimation: Unacceptable to SOCIALLY ACCEPTABLE ( man attracted to woman becomes her mentor) Suppression: CONSIOUS removal thought ( forget and retrievable)

Psychology random IQ: mental age/ chronological age X 100 ( if equal then 100 is avg )

-SD is 15 - below two SD is retardation

Less 70: mental retardationMild 70-50 (20) Self-supporting, with some guidance

Moderate 49-35 (14) Sheltered workshops, needs supervision (grade2)Severe 34-20 (14) Basic self care habits ( comb hair, pee, poo)Profound <20

Variable RATIO is the slowest to extinguish “ slot machine” Mental status changes what is lost first : time> place> person

-Most common dementia Alzheimers (stroke 2nd)- can be disoriented with

1. Alcohol/ drugs2. Electrolyte/ fluid imbalance 3. Head trauma 4. HYPOglycemia 5. Nutritional deficiencies

Greif : normal is up to 2 months- if more than 2 months pathological - Pathological also if excessively intense, absent or inhibited grief,

delusion hallucinations Child Abuse

1. Physical : usually mother / primary caregiver Osteogenesis imperfect is BLUE SCLERA (they might throw u off

with iris Retinal hemorrhage they will show a picture Subdural hematoma, multiple buise, cigarette burns

2. Sexual: usually male and known to victim, peak at 9-12* child neglect also needs to be reported to child protective services *Infant deprivation : long term deprivation of affection

- >6 months irreversible changes -severe can cause death

ADHD Lower frontal lobe volumes Normal IQ just difficulty focusing Treat with stimulants : Methylphenidate (increase NE and serotonin)

Autism Majority IQ LESS THAN 70 (mental retard) Social interaction not reciprocated ( no separation anxiety, don’t make eye

contact, don’t hold out arms to parents) Stereotyped behavior ( small interest number) Potential causes

* NOT ASSOCIATED WITH MMR Failure apoptosis cortex Prenatal/perinatal trauma and infection

* Aspergers ( NORMAL IQ and language ) Rett

X linked ( only seen in girls!, males they die) Normal develop till 4 and then regress Stereotypes hand-wringing

Childhood Disintegrative disorder Normal till 2 then regress (loss language, social skill, bladder/bowl control,

play motor skills) More in boys

Tourette’s Correlated with ADHD and OCD so can have all three Treat antipsychotics

Delirium and Dementia

Delirium: abnormal EEG Dementia : normal EEG Consciousness varies NORMAL

Causes Dementia 1. Alzheimer’s

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

Chromosome 19 ( Apoprotein E) Diffuse atrophy brain Can be reduction in choline acetyl transferase Die from infection (pneumonia) HIPPOCAMPUS affected first

2. Vascular dementia (stroke)3. HIV

HIV encephalitis and myelitis Kills brain cells and prevents their regeneration Most people with AIDS have HIV dementia Survive 4 months after onset HIV level in spinal cord good predictor Often misdiagnosed as depression

4. Picks Disease ( have tau also but neurofibrillary balls not tangle) Frontal and temporal lobes deteriorate

5. Lewy Body dementia ( FAST DEMENTIA , AND LEWY BODY IN CORTEX)6. Parkinsons ( late onset dementia, and lewy body in substantia nigra)7. Substance abuse ( neurotoxic 8. CJD (prions, protein that cause this) 9. Huntington Chorea 10. Wilsons

Defect in chromosome 13 Ceruloplasmin deficiency Copper accumulate in tissues ( cant be bound or excreted )

11. Normal Pressure hydrocephalus

Differentiate Alzheimer’s vs stroke HTN in Stroke Fast onset in stroke Stroke has other neurological signs that are lateralize ( EX sensory loss,

Alzhimers don’t have lateralized signs) Depression may present like dementia in elderly patients(PSEUDODEMENTIA)

Picks disease: temporal and frontal Alzhiemers whole brain

Psychology diseases

Psychotic DisordersSchizophrenia

Genetic predisposition ( if sibling or parent= 12 %, if both parents= 40%) Subtypes

1. Paranoid * better prognosis2. Catatonic : Increase or decrease activity

-Decrease: mute, rigid, echopraxia (repeat), automatic obedience -Increase: violent, destructive, repetitious stereotyped behavior

3. Disorganized * worst prognosis -disorganized speech, behavior, appearance, explosive laugh, grimacing

4. Undifferentiatted: combo of many5. Residual: has episode but on general exam look fine with no psychosis

Positive Symptoms : associated with Dopamine high (mesolimbic) Negative symptoms : associated with muscarninic ( Ach) Good prognosis :

-Paranoid -Late onset-FAST onset - Positive sympotms better than negative -no family history -* mood disorders better ( so schizoaffective better)

* differences: - Schizophrenic 2 weeks WITHOUT MOOD ( Schizoaffective) -IF Mood + psychotic together : Bipolar with psychotic features

Delusional disorder: Beliefs lasting >1 Fixed, non-bizarre ( woman thing shes a movie star) Functioning other than this is normal

Mood disorders Depression more in WOMEN Bipolar MEN= WOMEN ( MOST INHERITED PSYCHIATRIC DISEASE)

Depression sleep Increase REM sleep, and latency to it decrease ( get there faster) Decrease slow wave sleep (stage 4 the refreshing sleep)

Post partum 1. Blues : NORMAL, follow up in two weeks 2. Depression: 2 week- 2 months 3. Psychosis : days to weeks ( delusion, homicidal/suicidal)

Bipolar Need mood stabilizers: lithium, valproic acid (antiepileptic), carbamazepine atypical antipsychotics Hypomania doesn’t cause disturbance in social or occupational functioning

Suicide risks NUMBER ONE RISK : PERSON WHO HAS TRIED BEFORE Men succeed more, women try more

-success both from gun #1, women attempt with pills and poision Age : teens highest is natives, elderly (lowest is native) Race: white most Depression and alcohol number ones Lack of support, medical illness, sexual assault history

Anxiety disorders Obsessive compulsive disorder (EGO-DYSTONIC )

-Associated with tourettes Obsessive compulsive personality ( EGO-Syntonic) PTSD lasts more than a month

-can have long latency ( ex: abused child appear PTSD in adult)

Eating Disorders Anorexia BulimiaBMI < 17.5 Normal or overweight a bit

Binge and then compensateRestrictive and Purging types

purging can also throw up not just bulimia

Purging, non-purging

* at least twice a week for 3 month

Electrolyte imbalances ( HYPOKALEMIA, Electrolyte imbalance: hypokalemia and

leads to arrhythmias) alkalosis ( from vomiting acid)Lanugo : very fine bodily hairDental cavities

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

Somatoform DisordersSomatization: must have 4 pain, 2 GI, 1 sexual, 1 psuedoneuological Conversion: stress to physical neurological “la belle”Hypochondriasis: still think something wrong although results negative Pain disorder: prolonged pain with no physical finding

Factitious/ Muchausen: know faking it but drive unconscious Malingering: know faking and know drive

SexGender Dysphoria: not happy with their sex at birth ( usually change it Transsexual)

-born male, wants to be female, attracted to males (heterosexual)

SubstancePCPAM

1. precontemplation: don’t think they have a problem2. Contemplation: know have a problem but haven’t done anything 3. Preparation: make a plan 4. Action: change 5. Maintenance: prevent things that can relapse you6. Relapse

Substance dependence (BODY): Tolerance and withdrawalSubtance abuse (LIFE EFFECT): affect school, work, fail fulfill obligation, compulsive use (even if dangerous), legal issues

-All drugs work on dopamine mesolimbic reward pathway -Injection cause

- Right side endocarditis -Hepatitis, abscesses-HIV, AIDS

-overdose

Alcohol Wernike Korsakoff

Periventricular necrosis of mammillary bodies Wernike: confusion, ataxia, opthalmolegia ( cerebellum anterior

destroyed) Korsafoff: IRREVERSIBLE memory loss, confabulation, personality

(mammillary bodies) Wallory Weiss: longitudinal and painful vs esophagueal varies (painless) Treat : thiamine, sedative- hypnotics, lorazepam if seixure Withdrawal

1. Day 1: autonomic hyperactivity 2. 2: seizure 3. 3: Delirium Tremens: psychotic and confusion ( LIFE THREATENING)

Fetal Alcohol Syndrome: #1 cause mental retardation ( then Downs and Fragile X)

Conjunctiva injection: marijuana DepressantsOpiods ( morphine, heroine, methadone, codein, oxycodone)

Overdose : seizure Antedote : Naloxone/ naltrexone : opiod antagonist Flu like withdrawal (unpleasant but not life threatening) Treatment: Methadone LONG ½ life (safe in pregnancy)

Barbituates : no ceiling ( can die with overdose + withdrawal)-must treat withdrawal with barbiturate not benzo

Benzo: have ceiling effect (die with withdrawal)

-intoxication treat with FLUMAZENIL ( competitive GABA antagonist) -Withdrawal treat with long acting benzo (diazepam)

Stimulants Amphetamines( methamphetamine, crystal meth)

-euphoria, delusions, hallucinations -Increase Dopamine, NE, and serotonin (prevent uptake)

Cocain ( crack cocain) : -same as amphetamine-MI, sudden cardiac death, stroke (intense vasoconstriction), angina -withdrawal both meth and cocain is depression, fatigue, increased appetitie, suicide

MDMA/ Ecstacy/ Molly (amphetamine + hallucinogen) -High Serotonin -Hyperthermia, social LOVE, convulsion, DEATH -fatigue the day after

Caffiene: adenosine receptor antagonist, increase cAMP in neurons

Hallucinogens PCP (angel dust) : VIOLENT , ataxia, VERTICAL NYSTAGMUS + horizontal

-work on NMDA glutamate by blocking it Ketamine similar with NMDA LSD : increase serotonin

-visual hallucinations -Flash back years later

Marijuana -urine one month after use

*Inhalants look for crusting on the nose Anabolic steroids have LOW POTASSIUM Report physician to the person in charge of that level

Statistics

Accuracy: TP + TN / Total all Capture max infected people : 100% sensitivity, aka HIGH NPV, aka, FN=0

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

Alpha error: False true Beta error: False negative Power: True positive

- 1-beta - increases with

1. INCREASE SAMPLE SIZE 2. INCREASE EFFECT SIZE

Highest clinical evidence is the META-ANALYSIS Cross over study limits confounding variables

Reciever Operating Curve

Best is the Green (choose one with Grestest area under the curve)

Choose one with 90 degree angle This makes sensitivity highest Good for screening

Prevalence Sensitivity and specificity come with the test ( they don’t chancge with

Prevalence) Prevalence directly correlated with PPV increase together, NPV decrease Prevalnce= incidence X duration ( but can have incidence increase without

prevalence increase if the those who die or recover the same)

Sensitivty = NPV related due to False Negative Specificity = PPV due to False Positive Accuracy : TP + TN/ Total

Weird biases names Pygmalion: experimental expectancy “prophecy” Hawthorne: if group knows they are studied they act different Berkson: select patients only in the hospital

Variability Range: highest – lowest value SD(s) Variance (s^2) Standard Eror Mean (SEM) indirectly to population: as population increase

the SEM decreases

Hospitals/ Health insurance

Deductible : pay a certain rate always Copayment: if sick and get service they the patient pays some (less) and the

insurer more Private Insurer HMO Health Maintenance organization: prepaid group practice

Payment by capitation ( make money if patients not sick ) Members pay fixed price a month

Prefered Provider Organization PPO: Fee for service at a dscount Doctor makes money by NUMBERS (service discounted but more

patients) Government Paid Programs MediCARE : elderly > 65 and end stage renal disease

Part A: pay hospital Part B : pay physicians Part C : Medicare advantage ( through private companies include

benefits and can include PRESCRIPTION DRUGS) PART D: prescription drugs Still have deductibles and copay ( Medi CAID doesn’t)

MedicAID : health care for those on welfare Diagnostic related Groups

People put into groups based on age, condition, etc and there is a FIXED amount the govt will pay for them ( if it costs more not their problem since all patients in that group should get about the same treatments)

Negeatives 1. Earlier discharge form hospital ( so they don’t lose money)2. Upcoding: ILLEGAL to record a code that will pay more when u didn’t do

it

Ethics

When informing a patient of difficult information, the most appropriate course of action is to:1) immediately inform the patient of the bad news “you have cancer”2) give the patient a moment to think about and process the information3) explain what the bad news means for the patient4) answer any questions the patient may have

Capacity ( medical term) VS competence (legal term)

Competent unless 1. History suicide2. Psychotic 3. Patient cannot communicate

Therapeutic Privilege: The physician chooses what to do to unconscious or confused patient in order to protect their life

Locum Parentis: when parents cant be contacted and its an emergency doctor takes control

Written consent can be revoked anytime ORALLY If the treatment is pointless but family insists (MUST CONTINUE) VS brain dead

can stop even if they insist Mentally ill patients retain their rights, if they currently don’t have any odd

symptoms then they can choose medical things like refusing treatment NEVER refuse patient treatment, Participate in religious things with them if they ask you If patients want inappropriate treatment they cant have it Acknowledge and legitimize feelings

Life in U.SDivorce

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

-education of woman low

Social economic status : EDUCATION+ OCCUPATION DOESN’T INCLUDE INCOME!

EX: high income drug dealer, low SESPriest low income , high SES

Hgh SES better health except ( ANXIETY, BREAST CANCER, BIPOLAR) * think women over work ( breast cancer bc kids later)

Suicide Teens its on the rise bc of BULLYING

-highest risk is male, depressed and alcohol use -most have mental illness(therefore treat cause, not suicide symptom)-Native American most

Elderly > 65-native American least

Upper and middle class, white, Depression + alcohol 15%, schizophrenia 10%, borderline personality 5% Low serotonin is suicide (depression think) NEVER ASSIST SUICIDE ON USMLE

Health Heart disease #1 die Diagnosis

-Essential hypertension MEN -Pregnancy WOMEN

#1 malparactise suit : breast cancer Hospitalization

-most admissions: mental illness - most days : <3 - work related disability: muscular skeletal

HIV With AIDs right now then were homo/ bisexual With HIV right now IV drug abuse Recent increase transmission male female especially if on period Most dangerous sexual practice : ANAL SEX Mom HIV + then 100% kids test positive since antibodies transfer this is why

don’t do ELISA-do PCR to see if infected-RT-PCR to quantify amount virus * prevent transmission by giving AZT + C-SECTION + DON’T BREAST FEED

Reportable diseases Be A SSSMMART Chicken or your Gone with LYME B: Hepitits B A: heptatitis A

S: SyphilisS:salmonellaS:Shigella

M: mumpsM: measles A: AIDS R: Rubella T: T.B Chicken pox Gonorrhea + chlamydia Lyme disease Cancer: Women LUNG CANCER ON THE RISE Infant mortality :

Highest African Americans Native americans Latin and white low ( except Puerto Ricans)

Sexuality Avg age first sexual experience 16 50% done use regular birth control hightest teenage pregnancy: Hispanic highest black Native white

asia Highest incidence :HPV Chlamydia number one, then gonorrhea in teens Gender Identity stablished by 3 years old Everyone from baby to elderly MASTERBATE , its normal

Paraphilic Disorders Voyeurism : peeping tom Frotteurism: rubbing onto people Coprophilia : poop Urophilia: urination Necrophilia: dead people Hypoxyphilia: hypoxia during orgasm

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

Learning and Behavior Modification

Classical conditioning ( need something involuntary) NEW stimulus elicits SAME automatic action Stimulus generalization: ALL hospitals cause chemo patient to vomit Extinction: removing the Unconditioned STIMULUS from conditioned

STIMULUS will cause it CS CR to fade

Operant/ Instrumental Conditioning ( action voluntary Reinforcement increases the probability of doing an action

Reinforcement needs to be AFTER ACTION Continuous reinforcement: faster learn, faster extinction

Variable reinforcement : learn slower, slower extinction -Variable ratio: LEAST EXTINCTION “slot machine”

Spontaneous recovery: after extinction the response occurs randomly Secondary reinforcement: token associated with real reinforcement Therapy based on Operant

-Shaping: slowly move to desired action (autistic child) - Stimulus control: remove stimulus that trigger behavior Ex: drinking causes smoking -biofeedback -Extinction: discontinue reinforcement that is causing bad behavior ex: time out for misbehaving -Fading: gradually remove the reinforcement without them knowing

Behavioural therapy = classic conditioning Systemic desensitization: present the phobia in steps from least to most scared of but pair it with RELAXATION Exposure: just expose to complete fear Aversive conditioning: repel the person from

Behavioural models of Depression1. Learned Helplessness : even tho there is help they don’t take it

- all avoidance response is gone - “well nothing works why bother” - passive

2. Low rate of response- contigent reinforcement: -TOO LITTLE POSITVE REINFORCEMENT -may lack social skills to elicit positive reinforcement from peple

Special topics Anxiety: need medium anxiety to have optimum in performance Pain is subjective therefore we need to give drugs if they say they are in pain

-Time contingent in hospital -Pain contingent in Hospice ( self control and self administer)

Psychological Health and testing Holmes and Rahe rate stressful events ( the most stressful is DEATH SPOUSE)

-MORE STRESS= more unhealthy later -widow have higher rate of <3 attack in a year after spouce dies

IQ is a good predcotr of academic excellence IQ stable from 5 onwards IQ tests: Wechsler

1. WAIS-R : adults 2. WISC: 6-17 (children)3. WPPSI : 4-6 (preschool)4. Stanford- Binet Scale: 2-18

Personality Test

-Objective 1. Criterion referenced: results compared with present standard2. Norm referenced: referenced to normal

-MMPI : Minnesota Multiphasic personality inventory True and False test to over 550 things

-Projective test : ambiguous stimumuli 1. Rorschach Inkblot 2. TAT thematic apperception test: tell a story whats going on in pic 3. Scentence completion 4. Projective drawing: patient given paper and asked to draw something

Neuropsychological Tests “ TWO NAME TEST” - IQ IS HERE

Sleep cerebral cortex most affected by no sleep Is sleep deprived next sleep will have MORE STAGE 4, LESS REM REM LONGTERM MEMORY HIPPOCAMPUS

-latency in adults is 90 minutes Hormonal

-growth hormone increase -Prolactin increase bc dopamine decrease-serotonin increase ( initiate sleep) -TSH decrease “ cold at night”

REM NREMBrain ON, memory dream Brian offBody off (but erection here high Ach) Body on (sleep walking, jaw clench)Increase as night goes on Highest at first half nightDecrease if sleep deprived Increase if sleep deprived

Increase with exerciseDecrease after 80 Vanish in eldery stages 3 and 4 therefore

don’t feel rested

Neurotransmitters from initiate sleep to wake up “SANDman”Serotonin: help initiate sleepAcH: higher in REM NE: lowers REM Dopamine: produces arousal and wakefulness ( rises when waking)

-why Schizophrenics don’t sleep much

Narcolepsy Start with REM Cataplexy pathognomonic Have hallucinations before or after DEFICIENCY HYPOCRETIN / OREXIN ( cant regulate sleep)

SIDS ( unexplained death in sleep of kids under 1) IF PLACE ON BACK REDUCE RISK 50% Higher risk of mothers who smoke

Night terror NightmareIn stage 4 REMDon’t recall when woke up RecallPrecursor to temporal lobe epilepsy

Random Incidence: NEW EVENTS / those at risk Prevalence: ALL CASES( old + new) / total population at risk

If confidence interval doesn’t have null then statistically significant, and then the p value is LESS THAN 0.05

P value : less than 0.05 percent chance that the results obtained were due to chance-also 0.05 percent that this is an alpha/ type 1 error

confounding variable is is exposure- disease relationship can be described by another variable (confounder)

ARR= control- treatment

MODE IS MOST RESISTANT TO OUTLIERS

DIFF payment methods Capitation: doctors paid a fixed amount PER PATIENT (not service). Causes high preventative care

Fee for service: they are paid for every service therefore they don’t care about preventative medicine

Discounted fee for service

Salary : fixed salary therefore don’t care about the services or number or people.

TESTSTwo sample z test and two sample t test used to compare TWO GROUP, MEANS Chi- square test for CATEGORICAL DATA 2x2 table ANOVA: MEANS of 2 or more groups Meta analysis: pooling data from serveral studies to conduct an analysis having a larger STATISTICAL POWER

Power: 1- beta error - probability rejecting the null hypothesis when it is truly false - probability finding true relationship- depend on sample size. INCREASE SAMPLE SIZE INCREASE POWER - TYPICALLY SET AT 80%

TYPE 1 error is like specificity but False positive numberator Type 2 error like sensitivity

Berkson bias: selecting patients only hospitalized as the control group

Z score for 2 SD: 1.96Z score for 2SD : 2.58