USMLE Step 2 CK Lecture Notes Psychiatry and Epidemiology & Ethics‘AUTHORS Psychiatry ‘Alina Gonzalez-Mayo, M.D. Pryhiatist Roderick Shaner, M.D. Clinical Professor of Psychiatry Kack School of Medicine University of Southern Califrnia Los Angeles, California Epidemiology & Ethics Steven R. Daugherty, Ph.D. ‘Asstant Profesor of Pryehology Rush Medial College Chicago, Hos Dizetor of Edweation and Testing Kaplan MedicalContents Section 1. Psychiatry Chapter 1. Mental Status Examination... 1 Chapter 2. Pychic Structures oo... eesseeee sd ‘Chapter 3. Childhood Development ........... seeeeed Chapter 4. Childhood Disorders a Chapter 5. Mood Disorders cecceeeeeeeeesvetseneescsalT Chapter 6 Schizophrenia... eee seeereeee Chapter 7. Anciety Disorders... cescnensieee 38 Chapter 8. Somatoform Disorders .....s..secssvecesseees 7 Chapter 9. Cognitive Disorders... eee. sees cee wee Chapter 10, Dissociative Disorders... 0.0... ceeecceeeereeee st Chapter 11 Adjustment Disorders 35 Chapter 12. Substance Related Disorders a 7 ‘Chapter 13. Impulse Control Disorders... 63 (Chapter 14. ating Disorders ‘Chapter 15 Personality Disorders con (Chapter 16. Normal Sleep and Sleep Disorders . Chapter 17 Human Senualty ........ so ecee eee eee BS Chapter 18 Antipsychotic Medication... 89 ‘Chapter 19. Psychiatric Interventions... soos 9 ‘Chapter 20.Psychotherapies ..........+.00 imédicalSection Ul, Epidemiology & Ethics Chapter 1. Epidemiology ...-....+ eee 105 Chapter 2. Biostatistics .. Chapter 5. Ethics os. s.see Chapter 4. Public Health: SeltStudy ....SECTION | Psychiatry___ Mental Status Examination ‘The mental status examination is utd to describe the clinicians observations and impression ofthe patient during the interview In conjunction with the history of she patient, itis the best ‘way to make an accurate diagnosis, ‘General Description Appearance: grooming, poise, lathes, ody type (disheveled, neat, childlike, ee) Lehovons quantitative and qualitative aspects ofthe patent's motor behavior (restless, + Atul toward the examine: (cooperative, feank, and seductive) ‘Mood and Affect, ‘Mooi: emotions perceived by the patient (depressed, anxious, angry, et) + fet: patient's present emotional responsiveness (blunted, tail, et} + Appropratenss i reference to the contest ofthe sujet (appropri teorinapproprate) ‘Speech: The physical characteristics of spoech (selevant, coherent fluent.) Perceptual disturbances: Experienced in reference to sf or the environment (hallucinations, ilusions) Thought For of thought the way in which a person thinks (fight of ideas, loos associations, tangents, circumstantial, ec.) Content of though what che person is actualy thinking about (delusions, paranoia, and suicidal ideas) ‘Sensorium and Cognition Alertness and level of consciousness (awake, clouding of consciousness, et.) Orientation: time, place, and person -Memiory: cen, remot, recent pat, nd immediate retention and recall (Concentration and attention: serial seven, ability to spell backwards (Capacity to read and write: Ask patient to read a sentence and perform what it says ‘Visuospatial ability: copy a figure Asract thinking: similarities and proverb interpretation Fund of information and knowledge: calculating ability, name past presidents a iiédicalUSMLE Step 2: Psychiatry Impulse Control Estimated from history or bchavior during the iateview Judgment and tnsight:Ailty to act appropriately and sel-eflst Reliability: Physician's impressions ofthe patient’ ability to accurately ase his situation Interviewing Techniques (Open Fnded Questions: Allow the patent o speak nhs own words as much as possible Can you tll me shout the voices?” (Closed ded Questions: Ask fr specifi information without allowing optionsin answering “Are you hearing voices?” Facilitation: Physician helps the patient continue by providing verbal and nonverbal cues. “Yes, continue” Confrontation: Physician points something out to the patent “You are very upset today? Reassurance: If ruthful, can lead to increased compliance if false, can lead to decreased com- plianee “We both now that what you have i serious” (ruth) “Of course, everything will be allright” (fle) Leading: The answers suggested in the question. "Are che vos telling you to hurt yoursel®”Mental Status Examinatior ‘A 2oyearold man preset to your ofce complaining of autor haunts fr eppoxitely 7 months duo. He repr ering his the’ ice and al ies his mother’s wc as wel Te patent appears distressed bythe halucratons and wants yeu he Which ofthe allowing wou be the mos appropri setement a sme? (A) “What do he vices sap" © “Vave you talen mediation” (© “Wy do you thnk you hes vices” (©) “How sthe relationship with your peers” | © "Tel me about the wes” 12 As0}earold woman comes tose you ater her mother’s death apprasinatly 3 wees go. ‘ce then she hs complsined of depressed mod ane ens of ellessess. While in your ofc, se begins to cry hich of the folowing woud be the net step in the management of ‘hispaten? (8) “Twa come tack when you stop cing” (©) “Do you fea guity abou your mse’ dest" (© Ofertisue and cemain lent ©) “Coahead tis normal to oy" © Relea pshiaist or thes esaion lanations 1. Answer: EThe ideal intervening tecique so bein wth an open-ended question and i ccaclade wth dosed ended qesions Choices AC , and E ata open-ended | quests, Howevey, the best open ended question fr hs patent and he reason he cae | tose youis choice E. 2 Answer: C. One should abs express empathy ad ten ge the patent contol. By ‘of tssu, you are doing jst that. Choice Es alas coed.Psychic Structures 2 [de Drives (instints) presenta beth, There are only two drives: sex and aggression, go: Defense mechanisms, judgment, relation to reality, object reationships, developed shortly after birth Superego: Conscience, formed during latency period DEFENSE MECHANISMS ‘The way and means the ego wards off anxiety and controls instinctive urges and unpleasant fects (emotions). Defense mechanisms are: unconscious (exeept suppression), discret, dynamic and irreversible, andl adaptive and maladaptive, Types of Defense Mechanisms Projection: trib ng your own wishes thoughts, or flings onto someone ds, “Vm sure my wifes cheating on me Denia: Used to avoid becoming aware of some painful aspect of reality. Linon donot have cancer” Splicing: External objects are divided int al good ral bad ~The morning sf is much beter than the evening afl Blocking: Temporary block in thinking ant sem to remember his mame” Regression: Return toanealie sage of development, most inmate “Ever since my divorce, my 5-year has begun 1 wet the bes” Somatiaton:Paychie derivates ane converted into bodily symptoms “ust hiking ofthe exam I get butters in my stomach Introjection: Features ofthe external world are taken and made part ofthe sl. The eesideat physician dresses ike the attending. Displacement: An era 2 drives shited to another that resembles the orignal in some aspect. “tha to get of the dog since my husband kicked it very ime we had an argument” imedicalLUSMLE Step 2: Psychiatry 6 es feeling is withheld from consciousness unconscious forgetting. Repression: An idea “Ido not remember having had a dog” Intllectualization: Excessive ure of intellectual processes to avoid affecsve expression or expe- “vis interesting to note the specific skin lesions which seem to arise asa consequence cof my end-stage disease” Isolation: Separation ofan ies from the affect that accompanies it “As she asived atthe statin to identify the body, she appeared to show no emotion.” Rationalization: Rational explanations are used t0 justify unacceptable atitudes, belie oF behaviors, “Lid not pas the test because it was very dlc” Reaction formation: An unacceptable impulse is transformed into its opposite; results in the formation of character tats “Listen oi el his family he was not afi een Tah crying” ‘Undoing: Acting out the reverse ofan unacceptable behavior: consi ofan at 1 ned to wash my hands whenever Thave these thoughts” Acting out Behavioral or emotional outburst. Lat exlain why he has those emper tantrums” Humor Permits the expresion of felings and thoughts without personal discomfort "So" sid the 20-pound man, “they expected me to place my head between my legs i ‘theeventofa plane crash when the best could manage was placing my chin on my chest” Sublimation: Impulse gatication as been achieved but the aim or object has been changed ‘om unacceptable to acceptable allows instincts o be channeled. Most mature ofthe defenses. Jack the Ripper becomes a surgeon. Suppression: Conscious forgetting only conscious defense mechanism. “Tywould rather forget that my dog was run over by acaAru, working ine hospice, tas been ignoring an ede eral pant wo has teminal ances \When asked why she hasbeen gpoing the patent the cars rep, “She wats abe ef alone” (Which of he folowing defense mechanisms est explains her esponse? (Ratoni @) _tslsion of afet (© ntelecualzsion (©) Precion | © Densi : Answer. The ruses proecting et wishes by sting tet the patent want be lt ane when in realty she that wat ob Ie alone. Ratonalzaon & moking exes for your behav, Had | ths been the arse, she would have made exuses, such as Ses oo busy, i TESTS Intelligence Tests Intelligence Quotient (1Q) measures academic performance. 1Q= MAICA x 100; Mean 1Q = 100 (SD = 15) ‘Adults: Weehsler Adult Ineligence Scale Revised (WAIS-R) (Children: Weetslee Intelligence Seale for Cildven Revised (WISC-R) Stanford-Binet: Imligence sales Personality Tests Objective tests use simple simul, do not need much clinical expeienes: Minnesota Maliphesc Personality Inventory (MMP, rojective tests use ambiguous stimuli, need clinical experience, not diagnostic: Rorschach test (nkbot), Thematic Apperception Test (TAT) sentence completion, drawings. Neuropsychologic Tests Used to detect ongnity ftom any pschintre disorder; Render Ges, LaiaNebraks, Hates: RetnChildhood Development THEORIES ON HUMAN DEVELOPMENT Erik Erikson Erikson believed that human personality was determined by childhood and adult experiences. His theory of human development covers infancy to old age. His stages are determined by crises, which are the turning points ofthe stage. Stage 1 Stage. Stage Stage 4. Stage 5. Stage 6. Stage. Stage. Basic Trust versus Mistust (birth to 1 year) Enfints develop feeting of trust that thee wants willbe sated if paren i nt atin tive, the infant wil earn to mistrust, Autonomy versus Shame and Doubs (1 3 yeats) (Children havea sense of mastery over themselves and thee dives. They canbe oop- «erative o stubbora, They gain a sense oftheir separateness fom others. Initiative versus Gul (3 to 5 yeas) Iniites both motor and intellectual atvity. Sexual curiosity i present sibling rivaey. Industry versus Infririty (6 11 years) (Chile enters program of learning. Able to work andl aoguire adult skils, Children learn they are able to mister and complete a tsk, ‘dentty versus Role Diffusion (11 years through end of adolescence) Group identity; preoccupation with appearances. Deal with morality and ethic. Identity visi occurs atthe end ofthis stage, which Piaget called normative. Intimacy versus Isolation (21 1 40 years) Intimacy of sexual relations, friendships, and all deep associations are present. Ability to care and share with others without fear of losing sal Generatvty versus Stagnation (40 10 65 years) Having and raising children as well as other interests outside the home. If childless, development of altruiem and erestivty, Integity versus Despair (over 65 yeas) A sense ofsatisfiction with one ie Allows for an acceptance of one’s place in the lite cele iSticalLUSMMLE Step 2: Psychiatry 10 iia Jean Piaget Piaget beloved that intligeace was an extension of biologic adaptation and ad a logical struc ture. His theory consisted on how children and adolescents think and acquire knowledge. stage. Semsorinotor Stage birth 2 yeas) Infants begin to can through sensory cberation and xin conto of thee motor incions ough ati exploration, aad msipuatonof te event Object peancnc is ached Stage Preopeational Sige (2107 years) Qt wes sols and language mare extensively. Chile are egcenti, we nist thiing. and have a sense of manent sie Death reverse Lack the evo cnseraton Stage 3. Concrete Operations tage (7101 eas) accent is replaced by operational thong there they cn se thing ters perspective Have the lw of conservation death severable at the ag of 10 Stage. Formal Operations Sage 1 yer snd of dolce) ‘Abily think abstract, reason ductive and defn cones, Character by Aypotheial thinking and ductive reasoning. Sigmund Freud Freud believed that children were influenced by sexual drives. He noted that infants were capa- ble of sexial activity from birth, the inital stages being nongenital Stage t Stage 2 Stage 3. Stage 4. Stages. ‘Oral Stage (birth to 18 months) “The mouth isthe main ste of graiiation and is manifested by chewing, biting, and sucking Anal Stage (10 3 years) ‘The anus and surrounding areas are the main site of gratification, Primarily involved in bowel functions and bladder contol I hash toilet training, may become “anally fxatod”(obsssive-compelsive personality disorder) halle Stage (3 to 5 years), “The genital area isthe main site of gratification. Penis envy and fear ofeastation ane evident daring this tage. Increase in genital masturbation with fantasies involving the ‘opposite-sex parent, "Dedipal complex” Latency Stage (5 0 11-13 yeas) Formation ofthe superego, resolution of dhe Oedipal complex. Sexual interests dut= ing this period are believed tobe quiescent. Sublimation of sexual enetgy into ener sgetc lating and play activities, Genital Stage (11-13 0 adulthood) ‘Capacity for true intimacyChildhood Disorders MENTAL RETARDATION Definition. There must be significantly subaverage intellectual function (TQ less than 70), me sued bya varity of 19 tests. This must be accompanied by concurrent ipairmen in adapting to demands in school work, socal, and other environments The onset is before 18 yeas of age [Risk FactorsBtiology. Associated genetic and chromosomal abnormalities inchude inborn ‘errors of metabolism Ce ipidoses,aminoaciduras, glycogen storage diseases) and chromo: somal abnormalitis (eg, ci du chat syndrome, Down syndrome, fragile X syndrome). ‘Associated intrauterine infections inchide rubella, cytomegslovirs, and other viruses, Intrauterine exposure to toxins and other insults such as acolo, hypoxia, or malntition may be causal. Postnatal causes include exposure to toxins and infection, poor prenatal care, post natal exposure to heavy metal, physical trauma, and social deprivation, resenting Symptoms + Prevalence: 1% ofthe population. Occurs a 1:1 male-to-female ratio Mil retardation (1Q 50-70): Atain academic sil to approximately the sixth-grade level, often ive independently in the community or with minimal supervision, may have problems with impulse control and sl-esteem, and may have asocated con- duct disorders, ubstance-related disorders, an attention deficit hyperactivity disor- der (ADHD). Moderate rctardation (1Q 38-50): Atain academic skils toa second-grade level, may be able to manage activites of daily ving work in sheltered workshop, liv in esi- dential community settings, and have significant problems conforming to social ‘norms, Individuals with Down's syndrome are at high risk for erly development of Alsheimer’s disease. + Severe (1Q 20-35) and profound retardation (1Q Ss than 20) Lie or 0 speech, very Finite abilities to manage self-care, requires highly supervised care settings. Physical Examination. Evidence of under}ying disorder or injury Diagnostic Tests Amniocentesis: May reveal chromosomal abnormalities associated with mental tardation in high-risk pregnancies (mother >35 yeas of ae) “hestment, Primary prevention inclades genetic counseling, god prenatal care and safe nviron- ‘ments, eaten of associated general medial conditions may improve overall evel of cognitive and adaptive function. Special education techniques may improve ultimate lew! of function Behavioral guidance and atention to promoting self-esteem may improve longterm emotional adjustment Differential Diagnosis. Includes leaning end communication disorders, sensory impairment, autistic disorder, borderline intellectual functioning (1Q 70-100), and envren mental deprivation.USMLE Step 2: Psychiatry LEARNING DISORDERS: Definition, Characterized by lezning achievernent in specific areas that is substantially below ‘expectations, given the patients age, intelligence, sensory abies, and educational experience. ‘Types are reading dsotder (most common), mathematics disorder, and disorder of writen expeesion Risk Fecors/Etiology. Some cases ore dato the ffs of cosssting general medial conditions such as cerebral pay on the central neous sytem (CNS) function, Some general medical con- Gitons and substance-induced conditions are associated with learning disorders, including lead poisoning and fetal alcohol syndrome, Many cases have no abvious etiology. Presenting Symptoms + Preece: 5% of school-age children + Ons: wualy during elementary school + Peresptual-motor problems may be present. + Conduct sre poston defiant disonler and ADHD maybe present. + Poor seltestem and sci iamaturity maybe present + Schoo faire and behavioral dstarbances may out elicits sometimes persis into adulthood and interfere with occupational function. Diagnostic Tests. 1Q testing and acudemic achievement tests are the major diagnostic to's. “Treatment Special education to ensute general learning and maximize skills in the deficient ateasis the mainsay of treatment, Counseling of patients and families to improve self-esteem, ‘social behavior and family functioning is helpful Differential Diagnosis. Major rule-outs are environmental deprivation, hearing ot vision Impairment, and mental retardation. AUTISTIC DISORDER Definition. Qualitative impairments in social interaction, communication, imaginative activities, sand meres [isk Factors/Btiology. The cause is CNS damage due to known or unknown factors Sites of (CNS damage specifically asociated with autistic disorder are unknown. General medal condi tions associated with aisticdsonder include encephalitis mateznal rubella, PKU, tuberous se rosis fragile X syrrone, an perinatal anc, There is no obvious etiology in many case. Presenting Symptoms + Prevalence: 0.04% of the general population. Occurs a 5:1 male-to-female ratio. + Onset: Before 3 years of age + Soca symptoms: Lack of per relationships and a failure wo use nonverbal social ces + Communication symptoms: Absent or bizare use of speech + Behavioral symptoms: Odd preoccupation with repetitive activities, bizare manner jams, and igi adherence to purposes ritual + Mental retardation i present in 7506 of patients with autistic disorder, “+ Physical ndings Highs incidence of abnormal electroencephalograms (PEGS), seiautes and abnormal brain morphology