A heterogenous mix of epidemiology, biostatistics,

ethics, psychology, sociology and more falls under the

heading of behavioral science.

Pass Program
Behavioral science covers 5 major areas :
1. The mood and psychotic disorders
2. The pharm. associated with the above areas.
3. Personality disorders
4. Defense mechanisms
5. Sexual deviations

Mood and psychotic disorders

"The ups and downs"
Ups: anxiety and psychosis, in which every thing is up, e.g.
Heart rate.
Downs: depressive disorders, in which every thing is down, e.g.
Heart rate.
1. Sadness:
2. Grief:
Considered normal up to 12 months and after that, the term
depression is then applies.
It has five steps:
a. Denial. Don't speak about organ donation at this stage.
b. anger. 10% of couple who are grieving about their lost kid is lost
get divorced at this stage.

c. Bargaining ( magical thinking ) : Lord!, bring back my kid and

I will prey for you a lot!
d. Guilt:
e. acceptance
To help people go through these stages:
Show empathy ( I know how you feel ).
Group therapy
Offer compassion
3. Melancholy: deep type of sadness.
4. Dysthymia: minimal type depression for two years at least.
5. Cyclothymia: low level of depression and hypomania.
6. Bipolar:
a. Bipolar 1: major depression plus mania.
b. Bipolar 2: major depression plus hypomania ( an abnormality
of mood resembling mania but of lesser intensity ).

Mania is a complete loss of impulse control.

Is a distinct period of abnormally and persistently elevated,

expansive, or irritable mood lasting at least one weak. Diagnosis
requires 3 or more of the following to be present during mood
disorder: DIG FAST
1. Distractibility
2. Irresponsibility: seeks pleasure without regard to consequences
( hedonistic ).
3. Grandiosity
4. Flight of ideas- racing thoughts
5. Increased goal directed Activities/ psychomotor Agitation.
6. Decreed need for Sleep
7. Talkativeness or pressured speech.

Major Depression
Self-limited disorder, with major depressive episodes usually lasting
6-12 months, and impair the patient social function ( remember, grief
does not affect function ). Episodes characterized by at least 5 of
the following 9 symptoms for at least two weeks ( the patient must
report anhedonia, which is the most specific symptom of depression ):
SIG E CAPS.
1. Sleep disturbance
Life time prevelance of major
2. Loss of Interest
depressive episode:
3. Guilt or feeling of worthlessness
5-12% male, 10-25 female.
4. Loss of Energy
5. Lack of Concentration
6. Appetite/weight changes
7. Psychomotor retardation or agitation
8. Suicidal ideation ( learned hopelessness known to be correlated
with suicidal ideation ).
9. Depressed mode
Sleep disturbances in depressed people:
1. Excessive sleepiness
2. Short burst of REM ( so the patient don't feel refreshed
).
3. More REM overall sleep.
4. Early morning awakening.

Treatment of Depression
We use drugs that elevate the level of catecholamine.
Dopamine: nausea, vomiting, movement disorder
NorEpi.: sympathetic effects
Serotonin: sympathetic in the brain and parasympathetic in the
periphery.

Note: it takes about 6 weeks for the patient to feel better.

TCAs:
Four main effects:
1. Blocks catecholamine reuptake
2. Strongly anticholenergic ( impotence ).
3. Block alpha one receptors
4. Block A-V conduction leading to ventricular arrhythmia
( prolong QT interval ).

Imipramine: used for bed wetting

Amitriptyline: chronic pain and chronic neuropathy
Clomipramine: the only one that could be used for OCD ( though
its not the first choice )
Noretryptalline:
Used for elderly
Desipramine:
TCA intoxication is treated with a base ( e.g. Bicarb ) to pee it of.

SSRI's
Because these are slective for serotonin, there will be side effects
of norEpi or dopamine.
Serotonin acts as sympathetic in the brain and parasympathetic in
the periphery ( e.g. Big diarrhea ).
Anorgasmia is a marked side effect ( and as such, those drugs
could be used for premature ejaculation ).

Paroxetine:
Luvoxetine:
Fluoxetine ( Prozac ):
Sertraline:
Trazadone: remember priapism
Nefazidone:
These are now considered as heterocyclic because
the also affect norepi.

MAOI's:

Note: as we age, the level of MAO decrease, so catecholamine

are degraded more excessively, and this why depression is
more common in elderly. Note also, if the patient is already on
an MAOI and you want to shif him to an SSRI, you should wait
for 3-4 weeks. Otherwise, the patient will end up with
serotonin syndrome.

Tyramine

Metabolism

Octapine

Octapine is a very potent analog of norepi. So, when MAO

are knocked away with MAOI's, the patient run the risk of
developing big HTN.

Phenylzine
Isocaroxazid
Phenoxypropazine
Selegiline

Buproprion:
Work primary on serotonin and lil pit on Nore Epi.
Has lowest incidence of sexual dysfunction
Is not more effective than other antidepressant
Helps to stop smacking in 10-15% of smackers ( because of
reduction in depression in those people ).
Highest incidence of seizures ( so is not suitable for bulimic
because they commonly have electrolyte disturbances ).
Varenicline is a new
promising drug to assist
for smacking cessation.

ETC:

Indications:
1. Pregnancy ( antidepressant are C/I in pregnancy ).
2. Failure of the above meds.
3. Actively sucidal
Side effects:
Amnesia
Seizures: so premedicate with benzos.

Bipolar
> 1st line Rx is lithium
> Mechanism is unknown, but is thought to act like Na, competing with
it and blocking its channels so the cells can't become too +ve ( mania )
or too -ve ( depression ), so its a mood stabilizer.
> Because it looks like Na, it fools the kidney which looses Na. So hypo
Na is the most common side effect of lithium.
> It also fools the thyroid, which thinks its iodide. Hypothyroid is
expected.
> Fools the PTH receptors and increases Ca and decreases PO4.
> Block ADP receptors in the kidney, leading to nephrogenic DI.
( demeclocycline also causes this ).
> Increase incidence of Ebstein anomaly.

Valporic acid:
> For acute manis
> Blocks Na and Ca
> Side effects :
Bone marrow suppression
Hepatitis
Neural tube defects

Carbamazepine

> Blocks Na and Ca

> Used for temporal lobe seizure ( psychomotor seizure )
> Shooting neuropathy
> Side effects:
Agranulocytosis
Aplastic anemia
SIADH

Anxiety Disorders
1. Worry:
Situational and under control. Its an objective feeling.
2. Anxiety:
Its the external manifestation of being worry, i.e. worry is the
symptom and anxiety is the sign! This could be specific, e.g. Exam, or
generalized, e.g. Everything from the weather, the job, the future,
etc.
3. Anxiety disorder:
An anxiety turns into disorder when it causes social impairment.
4. Panik attack:
Sudden anxiet disorder.
5. Phobia:
Anxiet disorder plus avoidance behavior, e.g. Acrophobia,
arachnophobia, claustrophobia, agoraphobia ( fear of being out side,
considered the worst.
Note: phobia from snakes in female is proved to be due to
displacement because it reminds them the first painful intercourse!

Delusion:

Defense Mechanisms
Coping mechanisms

5. Suppression: when you consciously block something out. E.g.

Someone slab you and run away and, instead of chasing him, you say
to yourself " forget him, the god is watching. Some day I will get my
right".
6. Rationalization: making excuse for one's behavior.
7. Justification: is to make excuse after you have done something
wrong.
8. Projection: is to but your thoughts into someone else. The best
example is avertizing, they put something in the screen and you think
you need those things.
a. Transference: when the patient project the doctor
b. Counter transference: the doctor project to the patient.

9. Displacement is when you take it out in someone.

10. Splitting : just seeing everything as black or white.
11. Counterphobic behavior: to take an action that counter you won
phobia, e.g. Someone has hight phobia and he insist to climb.
12. Reaction formation: to act opposite to how you feel.
13. Sublimation: is making something positive out of something
negative. e.g. someone like to fight and beat people ( negative ) then
he become a professional wrestler ( positive ).
14. Intellectualization : pretending that you know it all to hide hour
ignorance of fear.
15. Undoing: do the exact opposite of what you used to be ( someone
used to set the fire and now he is fireman ).
16. Compensation: is to do something to makeup for what you used to
do. e.g. Someone used to burn people houses and now he donate for
people with burned people.

17. Idealization: is the feeling that everything has to be ideal.

E.g. A female dont get married because she think every man
should be as ideal as her father.
18. Idolization: statues, etc.
19. Immitation: you want to be just like someone you admire.
20. Identification: you want to dress like someone you admire.
Michel Jordon things.
21. Sexualization: to make something sexual out of everything.
22. Altruism: putting others before self.
23. Philanthropy: monitory giving to those who less fortunate.
24. Humor ( the most mature one ):

Laugh at yourself.

Treatment of Anxiety and Psychosis

Everything thing is up, So bring it down.
The best way to bring things down is do it by the way of the brain.
The most important inhibitory neurotransmitter in the brain is GABA
( serine is the spinal cord ).
Benzos and barbs are drugs of choice.
Benzos increase the frequency of Cl channel opening while barbs
increase the duration.
Intoxicated patients have the following pattern:
Everything is slowed down. The patients come with low energy state.
***
Note: benzos, barbs, alcohol and opioids all cause sedation, pin pupil
sets opioids apart ( this due to stimulation of Adenger-Westphal
nucleus )
The most important complications are the affecting CNS ( as usual ),
e.g. Respiratory depression.
***
Withdrawal from them all leads to excitation. Formication ( tactile
hallucination ) sets alcohol apart.
The most important complication is also CNS related ones, e.g. Seizure.
The most common cause of death is cardiac ( arrhythmia ), low
energy state man!

Benzos: ends in pam or lam.

Longest acting is flourezepam
Shortest acting is alprazelam followed by oxezepam and triazelam.
***
Alprazolam ( trade: Xanax ) is the DOC for anxiety and panic
attacks, X it out!
Triazolam is to help you TRY to get to sleep. Used in elderly who had
trouble in sleep initiation. side effect is anterograde amnesia.
Tamazepam is used to maintain sleep.
***
Four benzos are used to treat seizures:
1. Diazepam is the best of status for status epileptics ( SE )
2. Lorazepam is the second line in SE. It also comes in rectal
suppository to be used in seizing child. Its the best drug for anxiety
disorders in middle-aged female ( L for ladies! ).
3. Clonazepam is only benzo that could be used for absence seizure,
but the DOC is ethoximide.
4. Chlordiazepoxide is the DOC for delirium tremens.
So four main indications for benzos: seizures, muscle cramps, anxiety,
alcohol withdrawal, and insomnia.
***
Midozelam is used to do procedures such as proctoscopy.
****
Flumazenil is used for benzos intoxication.

Barbs:
> Phenobarbital is longest acting. Made his name for treatment of
generalized seizure in children ( a DOC ).
> Should not be used in porpheria.
> Primidone is the only one that is not ended in tal. Its the parent
compound of phenobarbital. So, in patient with past history of
allergy to this drug should not be given pheno. either.
> Thiopental is the shortest. Used in anesthesia protocols.
> Secobarbital is the most abused in the streets, remember Seko!
> Over dose is treat by:
a. HCO3 to pee it off then,
b. Doxapram to wake the patient up.

Note: of the four CNS inhibitors, withdrawal from opioids is the mildest! They
could be treated as out patient ( methadone clinics ). Withdrawal from others
should be hospitalized.

Anti-psychosis
It turned out that high dopamine is responsible for psychosis. So
all antipsychotics try to lower this neurotransmitter.
> Other effects of dopamine in the body:
1. Vomitting center : Chemotactic trigger zone in the area
postrema. So antipsychotics are also used as antiemetics.
2. Basal ganglia. Blocking of these would lead to extrapyramidal
symptoms. Examples Of these:
A. Dystonia: sustained contraction of group of muscles. Compare
this to a tic, which is spontaneous contraction of one muscle fibers.
The best example of dystonia is torticulus. Another one epistotanus.
B. Tardive dyskinasia ( TD ): abnormal fascial grimacing with tongue
trusting.
C. Aktheisa: is nonstop restless movement. This, a long with TD, does
not go away when treatment is stopped.
D. Parkinson: bradykanesia, shuffling gait, pill rolling tremor, etc.
E. Neuroleptic malignant syndrome: severe rigidity and
hyperthermia. This is treated by dantroline, which stabilizes SR.
3. Prolactin inhibition. This means that dopamine blocker will
elevate prolactin levels leading to galactorrhea. Prolactin also
blocks GnRH and TSH leading to amenorrhea and hypothyroidism.

Four categories of antipsychotics:

1. Phenothiazines
2. Thioxantheses
3. Butyrephenols
4. Atypicals

Phenothiazines:
Weak dopa blockers, i.e. less of these side effect.
Strongly anticholinergic ( hot, dry skin ).
Thioxantheses:
The same as phenos but the act longer so they are called depot
form.
So, as these two groups are weak antipsychotics, they are
used in mild psychosis, especially if the patient didn't sleep
for days ( their anticholeneric effect is sedating ).

Phenos:
1. Chlorpromazine ( Largactil ): also blocks alpha receptors ( leads to
hypotension ).
2. Perchlorperazine : antiemetic in adults.
3. Promethazine ( phenergan ) : antiemetic in children.
4. Fluphenazine: nothing especial
5. Thioridazine: pigmented retinopathy.
Thioxantheses: cheapest antipsychotics. For homeless,
imigrant worker, poor, etc.
1. Thiothixene: one injection last for 30 days.
Butyrephenols: potent dopamine blockers, so a lot of side effect.
They are used in active severe psychosis ( e.g. A patient tried to
kill ).
1. Haloperidol
2. Droperidol ( Vit H ).
Atypicals:
Not more effective than the others but have better profile.
Used when:
1. We have mostly negative symptoms ( e.g. Poor speech,
catatonia, social withdrawal, which have poor prognosis until
these drugs come along ).
2. Extrapyramidal occurs.

Atypicals ( D4 receptors ):
1. Clozapine:
Causes agranulocytosis ( a long with carbamazapine ) and seizures.
2. Olanzepine: massive weight gain and diabetes.
3. Resperidone: used with fantynel in anesthesia ( called
neurolepthanaesthesia )

Sexual Deviations
Pedophile : sexual pleasure derived from children
Urophile : sexual pleasure derived from being urinated upon
Coprophile: sexual pleasure derived from putting feaces upon them.
Necrophile : sexual pleasure derived from dead people.
Fetish: sexual pleasure derived from nonliving objects.
Voyeurism: sexual pleasure derived from watching others doing sex.
Frotteurism: sexual pleasure derived from rubbing up against closely
packed children.
Sadism: sexual pleasure derived from inflecting pain on someoneelse.
Masochism: sexual pleasure derived from having pain inflected on
me.
Transvestite: sexual pleasure derived from dressing like the other
sex ( the patient thinks he is a man but just want to dress like a
woman
Transexual: sexual pleasure derived from acting like the other sex, (
the patient think he is a female trapped in a male body ).

Beastophilia: sexual pleasure derived from having intercourse with

animals.
Exhibitionism: sexual pleasure derived from showing genitalia to
whom ever excite the patients.