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• Eating Disorders
• Child Development
• Affective and Thought Disorders
• Psychopharmacology
• Human Sexuality

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ANOREXIA NERVOSA:

• DIAGNOSTIC CRITERIA
• Intense fear of becoming fat even though underweight.
• Amenorrhea: At least 3 missed cycles in a row.
• Preoccupation with body weight and food.
• Body weight more than 15% below normal.
• Two Types:
• RESTRICTIVE ANOREXIA: No binge-eating and purging behavior. Weight controlled strictly by fastidious diet and exercise.
• BULIMIC TYPE: Behavior resembling bulimia
• Abuse of laxatives, diuretics, or enemas
• Binge eating and vomiting
• Medical Complications
• GI:
• Delayed gastric emptying.
• Constipation, but they won't complain of it.
• CNS: Abnormal EEG
• Skin: Fine hair on face and arms. Tiny ecchymoses indicative of increased capillary permeability.
• CV: Hypotension, arrhythmias, CHF.
• Hematologic: Leukopenia, bone marrow hypoplasia, thrombocytopenia.
• Endocrine: Decreased T_3, increased cortisol.
• EPIDEMIOLOGY:
• Predominantly (96%) female
• Usually has a positive family history. Major Depression is found in the family history, but not necessarily in the patient. Patient may be highly functional or accomplished (honor student, athletics, etc.)
• TREATMENT:
• SSRI's helpful for depressive symptoms and to aid in compliance with diet.
• Don't use tricyclics -- they cause weight gain and thus patient will not be compliant.
• Stabilize nutritional status, cardiac function, and electrolyte balance.

BULIMIA NERVOSA:

• DIAGNOSIS
• Behavior of binge eating is the predominant behavior. Binge Eating = episodic, uncontrolled ingestion of large quantities of food in a short time.
• Behavior occurs at least twice a week for at least three months.
• CHARACTERISTICS
• Often associated with chemical dependency (amphetamines)
• Often associated with compulsive stealing.
• Scars on back of hands from gagging.
• Guilt and awareness of one's own behavior, with cognitive recognition that it isn't healthy, but they still can't stop.
• SUBTYPES:
• PURGING: Binge-eating followed by vomiting.
• NON-PURGING: Binge eating interspersed with periods of prolonged fasting and exercise.
• MEDICAL PROBLEMS
• Potassium Depletion
• Dental erosion / caries

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MODELS OF CHILD DEVELOPMENT:

• ETHOLOGIC (DARWIN, BOWLBY)
• Deals with mother/child bonding and imprinting
• Deals with loss of superfluous neurons after birth (neuronal development and apoptosis)
• PSYCHOANALYTIC (FREUD):
• ORAL PHASE (BIRTH - 1 YR): Revolve around oral pleasure, self-satisfaction.
• ANAL PHASE (1-3 YRS): Toilet training; anal-retentive
• PHALLIC-OEDIPAL PHASE (3-5 YRS): Little boy falls in love with Mommy and wants to jump in bed and kill Daddy. Penis envy.
• LATENCY PHASE (5-12 YRS): Nothing. Smoldering
• GENITAL PHASE (11+ YRS): Adult sexuality and relationships
• PSYCHOSOCIAL (ERICKSON): Important for boards but not clinically.
• TRUST -VS- MISTRUST (BIRTH - 1 YR): Analogous to Freud's Oral Stage. Infant learns to trust his mother.
• AUTONOMY -VS- SHAME (1-3 YRS): Analogous to Freud's Anal Stage. Child learns to act alone.
• INITIATIVE -VS- GUILT (3-6 YRS): Analogous to Freud's Phallic Stage. Does child acquire guilt?
• INDUSTRY -VS- INFERIORITY (6-12 YRS): Analogous to Freud's Latency Stage. Mastery of grade school skills.
• IDENTITY -VS- ROLE CONFUSION (12-20 YRS): Adolescence. Time to discover yourself.
• INTIMACY -VS- ISOLATION (20-30 YRS): Form relationships or become a loner.
• GENERATIVITY -VS- STAGNATION (30-65 YRS): Mid-life crises.
• EGO INTEGRITY -VS- DESPAIR (65+ YRS): Depression or satisfaction.
• OBJECT RELATIONS THEORY (MAHLER): Development of individuation in infants and toddlers (1-3 yrs old).
• NORMAL AUTISTIC PHASE (BIRTH - 4 WEEKS): Child can't sense that he is a separate identify from parent. Existence strictly as extension of parent.
• NORMAL SYMBIOTIC PHASE (4 WEEKS - 5 MONTHS): Child can begin to identify an environment separate from parent, but still relies almost exclusively on parent.
• SEPARATION INDIVIDUATION PHASE (5 MONTHS - 36 MONTHS): Child begins to separate from parents.
• 1^ST SUB-PHASE -- DIFFERENTIATION (5-10 MONTHS): Child learns that he or she can walk away from Mom.
• 2^ND SUB-PHASE -- PRACTICING (10-16 MONTHS): Child practices independence. Walks away and comes back, walks away and comes back...
• 3^RD SUB-PHASE -- RAPPROACHMENT (16-24 MONTHS): Child throws tantrums in frustrating attempts at independence.
• 4^TH SUB-PHASE -- CONSOLIDATION and OBJECT CONSTANCE (24-36 MONTHS): Child build permanent picture of Mom and begins to understand that when Mom is absent, she will return.
• Do not confuse this with object permanence (Piaget), in which a child knows that an object is present when it is removed from site.
• COGNITIVE THEORY (PIAGET):
• SENSORIMOTOR (BIRTH - 2 YRS): Child develops Schema, patterns as to how things work.
• Object Permanence is acquired -- child knows an object is still there when it is removed from view.
• Child begins to learn the concept of causality. If I cry, then Mom comes.
• PREOPERATIONAL (2-7 YRS): Acquisition of declarative memory (memory of facts and events, which are represented symbolically, as opposed to how to do things) and language, the two of which must be co-acquired.
• They are unable to distinguish fact from fiction. Fantasies common.
• Personification: They typically attribute human feelings to inanimate objects.
• CONCRETE OPERATIONAL (7-11 YRS): Grade school.
• Acquire logical steps and sequencing.
• Understand conservation: pouring water from a tall glass into a fat glass.
• FORMAL OPERATIONAL (11+ YRS): Abstract and existential thinking. The ability to think about one's own thoughts.
• MORAL THEORY (GILLIGAN): What is right is what makes Mommy happy, and what is wrong is what makes Mommy angry.
• SOCIAL THEORY: Child imitation of parents.
• ATTACHMENT THEORY: Need for emotional comfort and security from Mommy.
• HARLOW: Infants preferred cloth mother over metal mother even when metal mother provided food.
• BOWLBY: Program infant to produce behaviors that elicit care-giving from adults.
• ATTACHMENT DISORDERS
• ANACLITIC DEPRESSION: Failure to thrive of infants in institution, given food but not given tender loving care.
• Psychosocial Dwarfism: Can result from neglect. Failure to thrive and hence no development.
• TEMPERAMENTAL DIFFERENCES IN INFANTS: Inherent, genetic traits in infants. These behavior dimensions remain stable over time
• Activity Level
• Rhythmicity
• Approach or Withdrawal
• Adaptability
• Intensity of Reaction
• Threshold of Responsiveness
• Distractibility
• Attention Span and Persistence
• LEARNING THEORIES

DEVELOPMENTAL DISORDERS

• SCHIZOPHRENIA can be considered a developmental disorder
• MENTAL RETARDATION: IQ below 70, and inability to function in society.
• Subtypes:
• Mild: Can achieve a sixth grade education. Cause is usually idiopathic, unknown.
• Moderate: Can achieve a second grade education.
• Severe: IQ < 30. The cause is usually known, such as genetic defect or birth trauma.
• GENETIC CAUSE: Most common is Down Syndrome.
• LEARNING DEFECT: Discrepancy between innate IQ and functional ability, such as dyslexia.
• PERVASIVE DEVELOPMENTAL DISORDER (PDD): Autism
• Deficits in three levels of function
• Language
• Social Interaction
• Stereotyped behaviors and interests
• ATTENTION-DEFICIT HYPERACTIVITY DISORDER (ADHD): Inattentiveness, Hyperactivity, Impulsiveness. The diagnosis must be made before age 7, or it is probably something else.
• Treat with Ritalin
• CONDUCT DISORDER: Disruptive and deviant.
• OPPOSITIONAL DEFIANT DISORDER
• PTSD: Can be diagnosed in kids who are victims of child abuse.

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SCHIZOPHRENIA: AXIS-I DISORDER

• SYMPTOMS
• Onset in early adolescence or childhood, and chronic progressive course without significant periods of relapse are the most important indicators of Schizophrenia. Partial remissions occur, but not full remissions.
• POSITIVE SYMPTOMS: Hallucinations, delusions.
• First-rank Symptoms: Not pathognomonic, but occur most frequently in Schizophrenics: Delusional perceptions, feelings of being controlled, thought broadcasting.
• NEGATIVE SYMPTOMS
• Flat Affect
• No Conation, no goal-directed behavior.
• Thought Disorder, word-salad.
• Downward Drift: Patients tend toward poverty, as a consequence of the disorder, as they cannot function well enough to prosper.
• PROGRESSION OF SYMPTOMS:
• PRODROME: Early signs. Patient begins to slip into a lack of goal-directedness. May drop out of school. May develop preoccupations or obsessions, or generally lose course.
• APOPHANY: Appearance of distinctly autistic, odd, near-delusional ideas. Subtle psychosis, discernable to a Psychiatrist, but if affective symptoms are present, than an affective disorder will be diagnosed at least initially.
• APOCALYPSE (ACTIVE): Florid, obvious psychosis.
• BURN-OUT (RESIDUAL): Can occur in remission, or especially with older age -- loss of positive symptoms, but the nnegative symptoms remain.
• BIOLOGICAL FINDINGS:
• Hypofunctioning Frontal Lobe: Could account for the thought disorder
• Hypoplastic Left Hemisphere: Smaller left hemisphere.
• Increased saccadic eye movements
• Increased autokinesis
• TREATMENT: ANTIPSYCHOTICS only treat the positive symptoms symptomatically. There is no treatment for the negative symptoms other than supportive therapy.
• EPIDEMIOLOGY:
• OUTCOME:
• 50% become chronically disabled
• 30% have a relapsing course, with periods of being able to function with difficulty, sometimes living on the fringe of society.
• 20% have fairly normal range of relationships and behaviors, although still troubled by the symptoms.
• RISK-FACTORS: Highly genetic.
• Siblings and Children have 10X greater risk
• Children of two schizophrenic parents have a 20X greater risk.
• 50% concordance in monozygotic twins, with the only difference being in how many symptoms (what threshold of diagnosis) you apply in doing the study. 100% of monozygotic twins have some symptoms.
• Tends to cluster in poor areas socioeconomically.
• People tend to have been born in late winter or early spring.
• SUBTYPES OF SCHIZOPHRENIA: Only use this designation where it is helpful in terms of treatment, prognosis, or therapy.
• PARANOID TYPE: Delusions and hallucinations (positive symptoms) are more prominent than the negative symptoms.
• Fairly good prognosis when treated, because positive symptoms can be treated.
• DISORGANIZED TYPE: Prominent loss of conation, profound thought-disorder, and a great deal of affective disturbance.
• Patients tend to be younger and tend to have a bad prognosis and rapid deteriorating course.
• UNDIFFERENTIATED: Waste-basket type, not fitting either of above.
• MILDER PSYCHOTIC ILLNESSES:
• SCHIZOPHRENIFORM ILLNESS: Acute illness, rapid onset, no prodrome, course of illness under six months. Patient should go into full remission, or else diagnosis may later be changed to full-blown Schizophrenia.
• SCHIZO-AFFECTIVE DISORDER: Superimposed schizophrenia with affective disorders. Despite the Kraeplinian Dichotomy (that they should remain separate), some researchers think that two separate diagnoses should be made.
• DELUSIONAL DISORDER: Adult onset. Delusions of jealousy or persecution only.
• ORGANIC HALLUCINOSIS: Visual and compelling hallucination without other symptoms. Alcohol or drugs may precipitate. Usually acute but can become chronic. Responds well to drugs.

BIPOLAR DISORDER:

• DIAGNOSIS: Episodes of mania alone are diagnostic for Bipolar disorder, since there is a 50% chance of depression to occur sometime in life, of any person who has a manic episode.
• SYMPTOMS: MANIA
• Decreased need for sleep
• No judgment
• Grandiosity, inflated self-esteem.
• Irritability, lost attention
• Unpredictability of emotions.
• BELL'S TOXIC MANIA can result in death.
• AGE: Tends to make the cyclic episodes shorter in duration, at shorter intervals, and more severe.
• EPIDEMIOLOGY:
• Equal M:F ratio (unlike depression which is predominantly female)
• 0.5% prevalence.
• Age of onset = 30, slightly younger than depression.

MAJOR DEPRESSION:

• SYMPTOMS
• Sleep Disturbances: Terminal Insomnia, middle insomnia, reduced REM Latency. Sleep is usually insomnia but maybe hypersomnia.
• Appetite disturbance, usually appetite loss.
• Neuroendocrine Disturbances
• Elevated Cortisol
• Dexamethasone Suppression Test: Synthetic cortisol should supress endogenous cortisol secretion, but it fails to in depressed people, yielding a positive test.
• Test is very specific for depression but unfortunately it is not sensitive.
• Reduced pituitary response to exogenous TRF (analogous to above) is also seen.
• Emotional / Cognitive Symptoms:
• Subjective complaints of poor memory, from poor concentration. Patient will actually complain of the memory loss, as compared to dementia, where patient has no clue (organic denial).
• Dysphoria, anhedonia
• Suicidal Ideation.
• EPIDEMIOLOGY: Risk Factors
• 20% overall prevalence.
• Age 35 or greater. Risk continually rises throughout old age.
• Female:Male by 2:1
• Genetic factor / positive family history.
• TREATMENT:
• Anti-Depressants: 15-25% of patients will remain symptomatic even with treatment.
• Cognitive Therapy
• Supportive Therapy
• Electroconvulsive Therapy (ECT): Safe and reliable in eliciting a remission of symptoms. It is the treatment of choice for those who cannot tolerate or do not respond to anti-depressants.
• POST-PARTUM DEPRESSION:
• In women with previous history, there is a 50% risk of experiencing an episode 6 months following delivery
• Inform the patient so the depression doesn't catch them unguarded.

SUICIDE:

• Risk in depression is about 15%, regardless of treatment with anti-depressants, although anti-depressants may prolong the occurrence to a later age.
• Women 10X more likely to attempt it, men 4X more likely to succeed.
• Cancer and other terminal illnesses have no correlation to suicide, except AIDS does correlate.
• Risk Factors for DEATH by suicide:
• Male
• Age > 40 years
• Being single, divorced, widowed, not married.
• Depression
• Alcoholism

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ANTIPSYCHOTIC DRUGS:

• Neuroleptic: Drugs that produce neurological symptoms
• Extra-pyramidal tremors
• Hypothalamic dysfunction (loss of appetite, thermoregulation, sleep)
• RAUWOLFIA ALKALOID: First drug discovered, originally prescribed as an anti-hypertensive + anti-psychotic.
• MECH: Blocks dopamine, NorE, and Serotonin
• PHENOTHIAZINE (CHLORPROMAZINE): Blocks Dopamine, Histamine, Acetylcholine, and alpha-Adrenergic receptors, all with same relative frequency
• DOPAMINE BLOCKADE: Produces the desired effect -- cancels the positive symptoms (symptomatic treatment only) of Schizophrenia
• Side Effects: Parkinsonian Symptoms, tremor, dyskinesia.
• Acute Dystonia: Sudden tonic contraction of neck and throat muscles.
• Akathisia: Inability to remain still.
• Tardive Dyskinesia: Late occurring involuntary repetitive jerking movements (prolonged use).
• NEUROLEPTIC MALIGNANT SYNDROME: Total rigidity of skeletal muscles, hyperthermia, renal failure.
• Acetylcholine antagonizes the action of Dopamine in the Basal Ganglia, thus this drug actually lessens the Parkinsonian side-effects, as long as the other side-effects can be tolerated, as in a young, healthy person.
• HISTAMINE BLOCKADE: Primary effect is to reduce agitation, when dose is proper.
• Side-Effect = Drowsiness
• ACETYLCHOLINE BLOCKADE:
• Decreased salivation
• Sweating
• Increased peristalsis, nausea, vomiting
• Tachycardia
• alpha-ADRENERGIC BLOCKADE: Orthostatic Hypotension -- block pre-arteriolar vasoconstrictive receptors.
• HALOPERIDOL (Haldol): Very specific for Dopamine, relatively sparing the ACh, Histamine, and alpha-Adrenergic effects.
• Thus it still can have pronounced Parkinsonian side-effects.
• This drug is preferred for old people, people of ill cardiovascular health, or others who can't handle the side effects.
• CLOZAPINE: Non-neuroleptic drug with unknown mechanism and relatively desirable side-effects.
• One bad Side-Effect is Agranulocytosis -- low WBC count, for unknown reasons.

ANTI-DEPRESSANT MEDICATIONS:

• MONO-AMINE OXIDASE INHIBITORS (MAOI's):
• Irreversibly inhibit Monoamine Oxidase, which normally degrades Norepinephrine at the post synaptic terminal.
• Side-Effects: Cannot use Tyramine. It doesn't get degraded in the gut and it stimulates NorE, giving us a double-whammy dose, which can lead to a hypertensive crisis.
• Tyramine found in aged foods like cheese, yogurts, sour cream, port wine. Also found naturally in banana peels and figs.
• Hyperpyrexia can also be seen, following administration of demerol.
• Hypotension, insomnia, and erectile impotence can also result.
• TRI-CYCLICS:
• MECH: They inhibit the reuptake of monoamine transmitters at the pre-synaptic membrane. They result in increased levels of Serotonin and Norepinephrine.
• Side-Effect: They are anticholinergic (block Acetylcholine), anti-histaminic (block Histamine), and anti-adrenergic (block alpha-Adrenergic receptors).
• They can produce or worsen heart-block, thus arrhythmias are a contraindication.
• They can contribute to heart failure be decreasing ejection fraction.
• SELECTIVE-SEROTONIN REUPTAKE INHIBITORS (SSRI's): Prozac. Like tri-cyclics, except they are very specific for Serotonin so they have much better side-effects.

ANTI-MANIC DRUGS:

• LITHIUM: Indicated for the treatment and prophylaxis of Mania.
• Effects noted 7-10 days after instituting treatment. It has a slow-acting effect (must build up blood levels), so it cannot be used to treat and acute episode of Mania, but only to prevent future episodes.
• Neuroleptics are the mainstay of early treatment for psychotic symptoms of mania.
• MECH: Really unknown. It is thought to reduce the cAMP-mediated signal transduction of certain neurotransmitter signals.
• SIDE EFFECTS:
• Mechanistic Side-Effects:
• Anti-Thyroid: Slows uptake of iodine and production of T₃. Can result in benign goiter -- adequate production thyroid hormone, but with a compensatory enlarged gland.
• Nephrogenic Diabetes Insipidus -- high volume low concentration urine, as it makes the distal tubules insensitive to ADH.
• Can counteract this side-effect by treating with thiazide diuretic, paradoxically, as it presents a greater load of sodium to the distal tubule, increasing the uptake of water there.
• The Therapeutic Index of Lithium is very narrow:
• Symptomatic effects at therapeutic concentrations (0.4 - 1.0 mEq/L): excessive thirst
• Symptomatic effects at high concentration (1.0 - 1.6 mEq/L): diarrhea, nausea, incoordination, poor attention.
• Symptomatic effects at toxic levels: Ataxia, confusion, stupor, coma, death.
• CARBAMAZEPINE is an anticonvulsant drug that can relieve manic symptoms when Lithium is ineffective.

ANTI-ANXIETY DRUGS:

• PANIC DISORDER: Treated with Tricyclics and MAOI's.
• SEDATIVE HYPNOTICS are used for short-term treatment of anxiety.
• Alcohol
• Tolerance, Cross-Tolerance, and Withdrawal

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THE PSYCHOSEXUAL ONION:

• GENOTYPIC SEX
• PHENOTYPIC SEX
• PELVIC PHENOTYPE
• CNS PHENOTYPE:
• 21-Ketolase Deficiency: Inability to convert estrogen to testosterone. As children they look like females and are usually treated as such.
• Micropenis
• Bifid Scrotum
• Normal testes that fail to descend.
• ASSIGNED SEX: The nature of one's primary sexual upbringing. How were they treated?
• SEXUAL SELF-IDENTITY: Individual's own sense of sexual identity.
• Transsexual: Sexual identity conflicts with phenotypic sex (but maybe not with CNS sex).
• SEXUAL OBJECT CHOICE: Heterosexual <====> Bisexual <====> Homosexual distribution curve, with most falling in the middle.
• SITUATIONAL PREFERENCES: Sexual deviations. From severe (sado-masochism) to mild (honey and whipped cream).
• CENTRAL / PERIPHERAL / GENITAL PHYSIOLOGY: Capacity for sexual excitement and resolution. Physical sexual behavior.
• SEXUALITY AS SOCIAL / INTERPERSONAL COMMUNICATION: Ability to form relationships. Most frequent source of complaint, if primary sex characteristics are okay.
• EXPECTATIONS
• STEREOTYPIC ASSUMPTIONS
• MORAL ASSUMPTIONS
• CULTURAL MYTHS

PHYSIOLOGY OF SEX:

• EXCITEMENT PHASE:
• Male Erection
• Female Lubrication
• PLATEAU PHASE:
• Male Pre-ejaculate
• ORGASMIC PHASE:
• RESOLUTION PHASE:

EFFECTS OF THE SEXUAL CYCLE:

• Central Anxiety has an inhibitory effect on the excitement phase.
• Depressive Illness greatly interferes with sexual desire -- all phases.
• Reactive Depression does not correlate with lessened sexual desire, but rather increased desire for affection. One good way to distinguish them.
• Antihypertensive Drugs -- alpha-adrenergic blockers and anti-dopamine drugs reduce the sexual response, which can lead to impotence.
• Antipsychotic Drugs may produce IMPOTENCE, loss of vaginal lubrication, or retrograde ejaculation.
• Alcohol can produce impotence.
• Spinal Cord Lesions: Can produce impotence, but the physical sexual response is still there, as long as pelvis splanchnics and sympathetics are intact. Thus at least the paraplegic can enjoy partner's responses and can perform sexually, with practice.
• AGE:
• Prolongs the time before you can get another erection.
• Often increases sexual desire in females (perhaps by increasing relative level of androgens).

SEXUAL DYSFUNCTIONS:

• MALE DISORDERS
• IMPOTENCE:
• Usually an organic or medial cause, although there may be psychological complications.
• TREATMENT = SENSATE FOCUS: Instruct couples not to have intercourse, but just to fondle and play. This can ultimately help couples overcome anxiety acquired from an episode of impotence.
• PREMATURE EJACULATION
• PRIAPISM: Persistent, unwanted, painful erection. Corpora Cavernosa are engorged while corpus spongiosum is not.
• MECH: Inability to relax smooth muscles draining the corpora cavernosa.
• FEMALE DISORDERS
• DYSPAREUNIA: Painful intercourse from any cause.
• VAGINISMUS: Psychogenic guarding reflex of spastic contraction of vagina upon entry of any object: instrument, finger, penis.
• TREATMENT: Desensitization. Gradual introduction of objects into vagina.
• Can occur after episodes of sexual assault or abuse.
• REDUCED VAGINAL LUBRICATION: Inadequate excitement phase. In females, it usually is psychological or affective.
• INHIBITED ORGASM: Some women involuntarily inhibit their own sexual response.

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