Behavioral science [7 ed.] 9781496349385, 1496349385, 9781496349392, 1496349393

Table of contents :
Front Cover
Title Page
Copyright Page
Dedication Page
Reviewers
Preface
CONTENTS
1. The Beginning of Life: Pregnancy Through Preschool
I. Childbirth and the Postpartum Period
II. Infancy: Birth to 15 Months
III. The Toddler Years: 15 Months–2½ Years
IV. The Preschool Child: 3–6 Years
Review Test
Answers and Explanations
2. School Age, Adolescence,
Special Issues of
Development, and
Adulthood
I. School Age: 7–11 Years
II. Adolescence: 11–20 Years
III. Special Issues in Child Development
IV. Early Adulthood: 20–40 Years
V. Middle Adulthood: 40–65 Years
Review Test
Answers and Explanations
3. Aging, Death, and
Bereavement
I. Aging
II. Stages of Dying and Death
III. Bereavement (Normal Grief ) Versus Complicated Bereavement (Depression)
Review Test
Answers and Explanations
4. Genetics, Anatomy, and Biochemistry of Behavior
I. The Genetics of Behavior
II. The Neuroanatomy of Behavior
III. Neurotransmission
IV. Biogenic Amines
V. Amino Acid Neurotransmitters
VI. Neuropeptides
Review Test
Answers and Explanations
5. Biological Assessment of Patients with Psychiatric Symptoms
I. Overview
II. Measurement of Biogenic Amines and Psychotropic Drugs
III. Evaluating Endocrine Function
IV. Neuroimaging and Electroencephalogram Studies
V. Neuropsychological Tests
VI. Other Tests
Review Test
Answers and Explanations
6. Psychoanalytic Theory and Defense Mechanisms
I. Overview
II. Freud’s Theories of the Mind
III. Defense Mechanisms
IV. Transference Reactions
Review Test
Answers and Explanations
7. Learning Theory
I. Overview
II. Habituation and Sensitization
III. Classical Conditioning
IV. Operant Conditioning
Review Test
Answers and Explanations
8. Clinical Assessment of Patients with Behavioral Symptoms
I. Overview of Psychological Testing
II. Intelligence Tests
III. Achievement Tests
IV. Personality Tests
V. Psychiatric Evaluation of the Patient with Emotional Symptoms
Review Test
Answers and Explanations
9. Substance-Related Disorders
I. Substance-related Disorders: Definitions, Epidemiology, and Demographics
II. Stimulants
III. Sedatives
IV. Opioids
V. Hallucinogens and Related Agents
VI. Clinical Features o Substance-related Disorders
VII. Management
Review Test
Answers and Explanations
10. Normal Sleep and Sleep Disorders
I. Normal Awake and Sleep States
II. Classification of Sleep Disorders
III. Insomnia
IV. Breathing-related Sleep Disorder (Sleep Apnea)
V. Narcolepsy
VI. Management o Sleep Disorders
Review Test
Answers and Explanations
11. Schizophrenia Spectrum and Other Psychotic Disorders
I. Schizophrenia
II. Other Psychotic Disorders
Review Test
Answers and Explanations
12. Depressive Disorders and Bipolar and Related Disorders
I. Overview
II. Classification of Depressive and Bipolar Disorders
III. Etiology
IV. Management
Review Test
Answers and Explanations
13. Anxiety Disorders, Somatic Symptom Disorders, and Related Conditions
I. Anxiety Disorders
II. Somatic Symptom and Related Disorders
III. Factitious Disorder, Factitious Disorder Imposed on Another, and Malingering
Review Test
Answers and Explanations
14. Neurocognitive, Personality, Dissociative, and Eating Disorders
I. Neurocognitive Disorders
II. Personality Disorders
III. Dissociative Disorders
IV. Obesity and Eating Disorders
Review Test
Answers and Explanations
15. Psychiatric Disorders in Children
I. Autism Spectrum and Related Disorders
II. Attention Def cit/Hyperactivity Disorder, Oppositional Def ant Disorder and Conduct Disorder
III. Other Disorders of Childhood
Review Test
Answers and Explanations
16. Biologic Therapies: Psychopharmacology
I. Overview
II. Antipsychotic Agents
III. Antidepressant Agents
IV. Mood Stabilizers
V. Antianxiety Agents
VI. Psychoactive Medications in Pregnancy
VII. Electroconvulsive Therapy and Related Therapies
Review Test
Answers and Explanations
17. Psychological Therapies
I. Psychoanalysis and Related Therapies
II. Behavioral Therapies
III. Other Therapies
Review Test
Answers and Explanations
18. The Family, Culture, and Illness
I. Overview of the Family
II. Demographics and Current Trends
III. Culture in the United States
IV. American Subcultures
Review Test
Answers and Explanations
19. Sexuality
I. Sexual Development
II. The Biology of Sexuality in Adults
III. Sexual Dysfunction
IV. Paraphilias and Paraphilic Disorders
V. Illness, Injury, and Sexuality
VI. Aging and Sexuality
VII. Drugs and Sexuality
VIII. The Human Immunodeficiency Virus and Sexuality
Review Test
Answers and Explanations
20. Aggression and Abuse
I. Aggression
II. Abuse and Neglect of Children, the Elderly, and Impaired Persons
III. Physical and Sexual Abuse o Domestic Partners
IV. The Role of the Physician in Suspected Child, Elder, and Domestic Partner Abuse
V. Sexual Aggression: Rape and Related Crimes
Review Test
Answers and Explanations
21. The Physician–Patient Relationship
I. Medical Practice
II. Adherence
III. The Clinical Interview
Review Test
Answers and Explanations
22. Psychosomatic Medicine
I. Stress and Health
II. Psychological Stress in Specific Patient Populations
III. Patients with Chronic Pain
IV. Patients with Acquired Immune Deficiency Syndrome
Review Test
Answers and Explanations
23. Legal and Ethical Issues in Medicine
I. Legal Competence
II. Informed Consent
III. Confidentiality
IV. Reportable Illnesses
V. Ethical Issues Involving HIV Infection
VI. Involuntary and Voluntary Psychiatric Hospitalization
VII. Advance Directives
VIII. Death and Euthanasia
IX. Medical Malpractice
X. Impaired Physicians
Review Test
Answers and Explanations
24. Health Care in the United States
I. Health Care Delivery Systems
II. Costs of Health Care
III. Payment for Health Care: Health Insurance
IV. Demographics of Health in the United States
Review Test
Answers and Explanations
25. Medical Epidemiology
I. Medical Epidemiology: Incidence and Prevalence
II. Research Study Design
III. Quantifying Risk
IV. Bias, Reliability, and Validity
V. Clinical Probability and Attack Rate
Review Test
Answers and Explanations
26. Statistical Analyses
I. Elements of Statistical Analyses
II. Hypothesis Testing
III. Statistical Tests
Review Test
Answers and Explanations
Comprehensive Examination
Answers and Explanations
INDEX
A
B - C
D
E
F - G - H
I
K - L
M - N
O
P
Q - R
S
T
U - V
W - X - Z

Citation preview

Beh avioral Scien ce S EVENTH EDITION

Beh avioral Scien ce S EVENTH EDITION

Barbara Fadem, Ph.D. Pro essor Dep artm en t o Psych iatry Ru tgers New Jersey Medical Sch ool Newark, New Jersey

Acqu isition s Editor: Crystal Taylor Produ ct Developm en t Editor: Ch ristin e Fah ey Editorial Assistan t: Brooks Ph elp s Marketin g Man ager: Mich ael McMah on Produ ction Project Man ager: Brid gett Dou gh erty Design Coordin ator: Holly McLau gh lin Man u factu rin g Coordin ator: Margie Orzech Prepress Ven dor: SPi Global Seven th Edition Copyright © 2017 Wolters Kluwer Copyrigh t © 2014, 2009, 2005 Lip p in cott, William s & Wilkin s, a Wolters Klu wer bu sin ess. All righ ts reserved. Th is b ook is p rotected by copyrigh t. No p art o th is b ook m ay be rep rodu ced or tran sm itted in an y orm or by an y m ean s, in clu din g as p h otocop ies or scan n ed-in or oth er electron ic cop ies, or u tilized by an y in orm ation storage an d retrieval system with ou t written p erm ission rom th e copyrigh t own er, excep t or brie qu otation s em bodied in critical articles an d reviews. Materials ap p earin g in th is book p rep ared by in d ivid u als as p art o th eir o icial d u ties as U.S. govern m en t em p loyees are n ot covered by th e above-m en tion ed copyrigh t. To requ est p erm ission , p lease con tact Wolters Klu wer at Two Com m erce Squ are, 2001 Market Street, Ph iladelp h ia, PA 19103, via em ail at p erm ission [email protected] , or via ou r website at lww.com (p rod u cts an d services). 9 8 7 6 5 4 3 2 1 Prin ted in Ch in a (or th e Un ited States o Am erica) Library of Congress Cataloging-in-Publication Data Nam es: Fadem , Barb ara, au th or. Title: Beh avioral scien ce / Barbara Fadem . Oth er titles: Board review series. Descrip tion : Seven th edition . | Ph iladelp h ia : Wolters Klu wer, [2017] | Series: BRS | In clu d es bibliograp h ical re eren ces an d in dex. Iden ti iers: LCCN 2015049524 | ISBN 9781496310477 Su b jects: | MESH: Beh avioral Scien ces | Beh avior | Exam in ation Qu estion s | Ou tlin es Classi ication : LCC RC457.2 | NLM WM 18.2 | DDC 616.890076—d c23 LC record available at h ttp :/ / lccn . loc.gov/ 2015049524 Th is work is p rovided “as is,” an d th e p u blish er disclaim s an y an d all warran ties, exp ress or im p lied, in clu din g an y warran ties as to accu racy, com p reh en siven ess, or cu rren cy o th e con ten t o th is work. Th is work is n o su bstitu te or in divid u al p atien t assessm en t based u p on h ealth care p ro ession als’ exam in ation o each p atien t an d con sid eration o , am on g oth er th in gs, age, weigh t, gen der, cu rren t or p rior m ed ical con d ition s, m edication h istory, lab oratory data an d oth er actors u n iqu e to th e p atien t. Th e p u blish er does n ot p rovide m ed ical ad vice or gu id an ce an d th is work is m erely a re eren ce tool. Health care p ro ession als, an d n ot th e p u b lish er, are solely resp on sib le or th e u se o th is work in clu d in g all m ed ical ju dgm en ts an d or an y resu ltin g d iagn osis an d treatm en ts. Given con tin u ou s, rap id ad van ces in m ed ical scien ce an d h ealth in orm ation , in dep en d en t p ro ession al veri ication o m edical diagn oses, in dication s, ap p rop riate p h arm aceutical selection s an d dosages, an d treatm en t op tion s sh ou ld b e m ade an d h ealth care p ro ession als sh ou ld con su lt a variety o sou rces. Wh en p rescrib in g m edication , h ealth care p ro ession als are advised to con su lt th e p rod u ct in orm ation sh eet (th e m an u actu rer’s p ackage in sert) accom p an yin g each dru g to veri y, am on g oth er th in gs, con dition s o u se, warn in gs an d sid e e ects an d id en ti y an y ch an ges in dosage sch ed u le or con train dication s, p articu larly i th e m ed ication to b e adm in istered is n ew, in requ en tly u sed or h as a n arrow th erap eu tic ran ge. To th e m axim u m exten t p erm itted u n der ap p licable law, n o resp on sibility is assu m ed by th e p u blish er or an y in ju ry an d/ or d am age to p erson s or p rop erty, as a m atter o p rod u cts liab ility, n egligen ce law or oth erwise, or rom an y re eren ce to or u se by an y p erson o th is work. LWW.com

I lovingly dedicate the seventh edition o this book to Daniel, J onathan, Terri, Sarah, and J oseph Fadem and Tom, Fif , and Hasu Chenal

Reviewers

Instructors: Frank G. Baugh, Ph.D. Dean , Sch ool o Natu ral an d Beh avioral Scien ces William Carey Un iversity Stacey Kaltm an, Ph.D. Associate Pro essor Dep artm en t o Psych iatry Assistan t Director Cen ter or Trau m a an d th e Com m u n ity (CTC) Georgetown Un iversity Quentin T. Sm ith, M.D., DLFAPA Vice Ch air Pro essor Psych iatry an d Beh avioral Scien ce Moreh ou se Sch ool o Medicin e Jennifer Zorn, M.S., PA-C Associate Pro essor Ph ysician Assistan t Program Bu tler Un iversity Students: Yasir Al Shebib Im am Un iversity Petra Brayo Tem p le Un iversity Sch ool o Medicin e

Christina Cherry New York In stitu te o Tech n ology College o Osteop ath ic Med icin e Christin Giordano Un iversity o Cen tral Florida College o Medicin e Cinthia M. Gonzalez San Ju an Bau tista Sch ool o Medicin e Sam irah Javed San Fran cisco State Un iversity Muneez Javed Am erican Medical Stu den t Association San Fran cisco State Un iversity Am anda Lucashu Tou ro College o Osteop ath ic Med icin e Monica Mattes Un iversity o Cen tral Florida Nasim a Mehraban Sain t Jam es Sch ool o Medicin e Katie Vannatta Kan sas City Un iversity o Medicin e an d Bioscien ces Michael Wu Joh n A. Bu rn s Sch ool o Medicin e Un iversity o Hawaii

vii

Pre ace

Th e u n ction an d state o th e m in d are o sign i ican t im p ortan ce to th e p h ysical h ealth o an in dividu al. Th e Un ited States Medical Licen sin g Exam in ation (USMLE) is closely attu n ed to th e su b stan tial p ower o th e m in d –bod y relation sh ip an d exten sively tests th is area on all th ree step s o th e exam in ation . Th is review book was p rep ared as a learn in g tool to h elp stu d en ts rap idly recall in orm ation th at th ey learn ed in th e irst 2 years o m edical sch ool in beh avioral scien ce, p sych iatry, ep id em iology, an d related cou rses. Th e seven th edition o BRS Beh avioral Scien ce con tain s 26 ch ap ters. All ch ap ters start with a “Typ ical Board Qu estion ,” wh ich serves as an exam p le or th e m an n er in wh ich th e su bject m atter o th at ch ap ter is tested on th e USMLE. Each ch ap ter h as been u p dated to in clu de th e m ost cu rren t in orm ation . Ap p roxim ately 770 USMLE-style qu estion s with detailed an swers an d exp lan ation s are p resen ted in each ch ap ter, as well as in th e Com p reh en sive Exam in ation . A sign i ican t n u m b er o th ese qu estion s were written exp ressly or th is seven th edition an d re lect USMLE style, u sin g clin ical vign ettes in th e stem . Man y tab les are in clu ded in th e book to p rovide qu ick access to essen tial in orm ation .

ix

Ackn owledgm en ts

Th e au th or wish es to th an k Crystal Taylor o Wolters Klu wer, Lip p in cott William s & Wilkin s, or h er en cou ragem en t an d p ractical assistan ce with th e m an u scrip t. As always, th e au th or th an ks with great a ection an d resp ect th e carin g, in volved m edical stu den ts with wh om sh e h as h ad th e h on or o workin g over th e years. Sp ecial th an ks to Meredith Bran don , M.D., or h er in p u t in to Ch ap ter 16.

xi

Con ten ts

Review ers vii Preface ix Ack n ow ledgm en ts

1.

xi

THE BEGINNING OF LIFE: PREGNANCY THROUGH PRESCHOOL I. II. III. IV.

1

Ch ildbirth an d th e Postp artu m Period 1 In an cy: Birth to 15 Mon th s 3 Th e Toddler Years: 15 Mon th s–2½ Years 5 Th e Presch ool Ch ild: 3–6 Years 6

Review Test 8

2.

SCHOOL AGE, ADOLESCENCE, SPECIAL ISSUES OF DEVELOPMENT, AND ADULTHOOD I. II. III. IV. V.

Sch ool Age: 7–11 Years 15 Adolescen ce: 11–20 Years 16 Sp ecial Issu es in Ch ild Develop m en t Early Adu lth ood: 20–40 Years 19 Middle Adu lth ood: 40–65 Years 19

15

18

Review Test 20

3.

AGING, DEATH, AND BEREAVEMENT

25

I. Agin g 25 II. Stages o Dyin g an d Death 27 III. Bereavem en t (Norm al Grie ) Versu s Com p licated Bereavem en t

(Dep ression )

27

Review Test 29

xiii

xiv

4.

Contents

GENETICS, ANATOMY, AND BIOCHEMISTRY OF BEHAVIOR I. II. III. IV. V. VI.

34

Th e Gen etics o Beh avior 34 Th e Neu roan atom y o Beh avior 35 Neu rotran sm ission 37 Biogen ic Am in es 38 Am in o Acid Neu rotran sm itters 41 Neu rop ep tides 41

Review Test 42

5.

BIOLOGICAL ASSESSMENT OF PATIENTS WITH PSYCHIATRIC SYMPTOMS I. II. III. IV. V. VI.

Overview 49 Measu rem en t o Biogen ic Am in es an d Psych otrop ic Dru gs Evalu atin g En docrin e Fu n ction 50 Neu roim agin g an d Electroen cep h alogram Stu dies 50 Neu rop sych ological Tests 51 Oth er Tests 52

49 49

Review Test 53

6.

PSYCHOANALYTIC THEORY AND DEFENSE MECHANISMS 57 I. II. III. IV.

Overview 57 Freu d’s Th eories o th e Min d De en se Mech an ism s 58 Tran s eren ce Reaction s 58

57

Review Test 61

7.

LEARNING THEORY I. II. III. IV.

Overview 65 Habitu ation an d Sen sitization Classical Con dition in g 66 Op eran t Con dition in g 66

65 65

Review Test 69

8.

CLINICAL ASSESSMENT OF PATIENTS WITH BEHAVIORAL SYMPTOMS 74 I. Overview o Psych ological Testin g II. In telligen ce Tests 74

74

xv

Contents

III. Ach ievem en t Tests 75 IV. Person ality Tests 76 V. Psych iatric Evalu ation o th e Patien t with Em otion al Sym p tom s

76

Review Test 79

9.

SUBSTANCE-RELATED DISORDERS

83

I. Su bstan ce-related Disorders: Def n ition s, Ep idem iology, an d II. III. IV. V. VI. VII.

Dem ograp h ics 83 Stim u lan ts 84 Sedatives 85 Op ioids 87 Hallu cin ogen s an d Related Agen ts 88 Clin ical Featu res o Su bstan ce-related Disorders Man agem en t 90

89

Review Test 91

10.

NORMAL SLEEP AND SLEEP DISORDERS I. II. III. IV. V. VI.

Norm al Awake an d Sleep States 98 Classif cation o Sleep Disorders 100 In som n ia 100 Breath in g-related Sleep Disorder (Sleep Ap n ea) Narcolep sy 102 Man agem en t o Sleep Disorders 103

98

102

Review Test 104

11.

SCHIZOPHRENIA SPECTRUM AND OTHER PSYCHOTIC DISORDERS I. Sch izop h ren ia 111 II. Oth er Psych otic Disorders

111

114

Review Test 116

12.

DEPRESSIVE DISORDERS AND BIPOLAR AND RELATED DISORDERS I. II. III. IV.

Overview 121 Classif cation o Dep ressive an d Bip olar Disorders Etiology 124 Man agem en t 126

Review Test 127

122

121

xvi

13.

Contents

ANXIETY DISORDERS, SOMATIC SYMPTOM DISORDERS, AND RELATED CONDITIONS 132 I. An xiety Disorders 132 II. Som atic Sym p tom an d Related Disorders 135 III. Factitiou s Disorder, Factitiou s Disorder Im p osed on An oth er, an d

Malin gerin g

136

Review Test 137

14.

NEUROCOGNITIVE, PERSONALITY, DISSOCIATIVE, AND EATING DISORDERS I. II. III. IV.

144

Neu rocogn itive Disorders 144 Person ality Disorders 148 Dissociative Disorders 149 Obesity an d Eatin g Disorders 150

Review Test 153

15.

PSYCHIATRIC DISORDERS IN CHILDREN

160

I. Au tism Sp ectru m an d Related Disorders 160 II. Atten tion Def cit/ Hyp eractivity Disorder, Op p osition al Def an t Disorder

an d Con du ct Disorder 161 III. Oth er Disorders o Ch ildh ood

163

Review Test 164

16.

BIOLOGIC THERAPIES: PSYCHOPHARMACOLOGY I. II. III. IV. V. VI. VII.

Overview 169 An tip sych otic Agen ts 169 An tid ep ressan t Agen ts 171 Mood Stabilizers 175 An tian xiety Agen ts 175 Psych oactive Medication s in Pregn an cy 176 Electrocon vu lsive Th erapy an d Related Th erap ies

169

177

Review Test 179

17.

PSYCHOLOGICAL THERAPIES I. Psych oan alysis an d Related Th erap ies II. Beh avioral Th erap ies 188 III. Oth er Th erap ies 189 Review Test 191

187 187

Contents

18.

THE FAMILY, CULTURE, AND ILLNESS I. II. III. IV.

Overview o th e Fam ily 195 Dem ograp h ics an d Cu rren t Tren ds Cu ltu re in th e Un ited States 197 Am erican Su bcu ltu res 198

xvii

195

195

Review Test 200

19.

SEXUALITY I. II. III. IV. V. VI. VII. VIII.

Sexu al Develop m en t 205 Th e Biology o Sexu ality in Ad u lts 206 Sexu al Dys u n ction 207 Parap h ilias an d Parap h ilic Disorders 209 Illn ess, In ju ry, an d Sexu ality 210 Agin g an d Sexu ality 210 Dru gs an d Sexu ality 211 Th e Hu m an Im m u n odef cien cy Viru s an d Sexu ality

205

211

Review Test 213

20.

AGGRESSION AND ABUSE

220

Aggression 220 Abu se an d Neglect o Ch ildren , th e Elderly, an d Im p aired Person s 221 Ph ysical an d Sexu al Abu se o Dom estic Partn ers 223 Th e Role o th e Ph ysician in Su sp ected Ch ild, Elder, an d Dom estic Partn er Abu se 224 V. Sexu al Aggression : Rap e an d Related Crim es 224

I. II. III. IV.

Review Test 226

21.

THE PHYSICIAN–PATIENT RELATIONSHIP

232

I. Medical Practice 232 II. Adh eren ce 233 III. Th e Clin ical In terview 235 Review Test 238

22.

PSYCHOSOMATIC MEDICINE I. II. III. IV.

Stress an d Health 248 Psych ological Stress in Sp ecif c Patien t Pop u lation s 250 Patien ts with Ch ron ic Pain 251 Patien ts with Acqu ired Im m u n e Def cien cy Syn drom e 252

Review Test 253

248

xviii

23.

Contents

LEGAL AND ETHICAL ISSUES IN MEDICINE I. II. III. IV. V. VI. VII. VIII. IX. X.

258

Legal Com p eten ce 258 In orm ed Con sen t 259 Con f den tiality 260 Rep ortable Illn esses 260 Eth ical Issu es In volvin g HIV In ection 261 In volu n tary an d Volu n tary Psych iatric Hosp italization Advan ce Directives 262 Death an d Eu th an asia 262 Medical Malp ractice 263 Im p aired Ph ysician s 264

261

Review Test 265

24.

HEALTH CARE IN THE UNITED STATES I. II. III. IV.

278

Health Care Delivery System s 278 Costs o Health Care 280 Paym en t or Health Care: Health In su ran ce 280 Dem ograp h ics o Health in th e Un ited States 283

Review Test 285

25.

MEDICAL EPIDEMIOLOGY I. II. III. IV. V.

290

Medical Ep idem iology: In ciden ce an d Prevalen ce Research Stu dy Design 291 Qu an ti yin g Risk 291 Bias, Reliability, an d Validity 293 Clin ical Probability an d Attack Rate 296

290

Review Test 298

26.

STATISTICAL ANALYSES I. Elem en ts o Statistical An alyses II. Hyp oth esis Testin g 309 III. Statistical Tests 310 Review Test 312

Comprehensive Examination Index

353

317

306 306

c ha pte r

1

Th e Begin n in g o Li e: Pregn an cy Th rou gh Presch ool

Typical Board Question Th e eld erly gran d ath er o two ch ild ren , on e aged 2 years an d on e aged 4 years, h as recen tly died . Th e ch ildren’s gran d ath er was very in volved in th e care o th e ch ildren . Wh en th e ch ildren are told ab ou t th e death , th e typ ical p ercep tion o th eir gran d ath er’s death or th e 2-year-old an d th e 4-year-old , resp ectively, is m ost likely to be th at th e death

(A) (B) (C) (D) (E)

is aban don m en t; is p u n ish m en t is p u n ish m en t; is aban don m en t is p u n ish m en t; is irreversib le is ab an d on m en t; is irreversib le is irreversib le; is p u n ish m en t

(See “An sw ers an d Explan ation s” at th e en d of th e ch apter.)

I. CHILDBIRTH AND THE POSTPARTUM PERIOD A. Birth rate in the United States and cesarean birth 1. Abou t 4 m illion ch ildren are born each year in th e Un ited States. 2. Abou t on e-th ird o th ese b irth s are by cesarean section . 3. Th e n u m ber o cesarean birth s declin ed du rin g th e 1990s, p artly in resp on se to in creasin g evid en ce th at wom en o ten u n dergo u n n ecessary su rgical p roced u res. From 2000 to 2009, Th e rate was in creasin g bu t sin ce 2009 th e rate h as been declin in g again .

B. Premature birth 1. Premature births an d very premature births are d e in ed as th ose ollowin g a gestation o less th an 37 an d 32 completed weeks , resp ectively. 2. Prem atu re b irth p u ts a ch ild at greater risk or dyin g in th e irst year o li e an d or em otion al, beh avioral, an d learn in g p roblem s as well as physical an d intellectual disabilities . 3. Prem atu re b irth s, wh ich are associated with low in com e, m atern al illn ess or m aln u trition , an d you n g m atern al age, occu r in alm ost twice as m an y n on -Hisp an ic A rican -Am erican in an ts th an n on -Hisp an ic Wh ite in an ts.

C. Infant mortality 1. Low socioeconomic status , wh ich is related in p art to eth n icity, is associated with p rem atu rity an d h igh in an t m ortality (Table 1.1). 2. In p art, becau se th e Un ited States d oes n ot h ave a system o h ealth care or all citizen s p aid or by th e govern m en t th rou gh taxes, p rem atu rity an d in an t m ortality rates in th e Un ited States are h igh as com p ared to th e rates in oth er develop ed cou n tries (Figu re 1.1).

1

2

BRS Behavioral Science t a b l e

1.1

Ethnicity and Infant Mortality in the United States (2010)

Ethnic Group

Infant Deaths Per 1,000 Total Live Births

All ethnic groups Asian or Pacific Islander

6.14 4.27

Non-Hispanic White

5.18

Hispanic

5.25

Native American Non-Hispanic Black (African American)

8.28 11.46

From Matthews TJ, MacDorman M. Infant mortality statistics from the 2010 period: Linked birth/infant death set. Natl Vital Stat Rep. 2013;62(8):1–26.

3. Th e Apgar score (named for Dr. Virginia Apgar but useful as a mnemonic): A—appearance (color), P—pulse (heartbeat), G—grimace (reflex irritability), A—activity (muscle tone), R—respiration (breathing regularity), qu an ti ies p h ysical u n ction in g in p rem atu re an d u ll-term n ewborn s (Table 1.2) an d can be u sed to p redict th e likelih ood o im m ediate su rvival. Th e in an t is evalu ated 1 m in u te an d 5 (or 10) m in u tes a ter birth . Each o th e ive m easu res can h ave a score o 0, 1, or 2 (h igh est score = 10). Score >7 = n o im m in en t su rvival th reat; score 2 mo

Moderate symptoms subside within 1 y

Moderate symptoms persist for >1 y

Management includes increased calls and visits to the physician, grief peer support groups, and short-acting sleep agents, e.g., zolpidem (Ambien) for transient problems with sleep

Management includes antidepressants, antipsychotics, electroconvulsive therapy, as well as increased contact with the physician

Adapted from Fadem B. Behavioral Science in Medicine. 2nd ed. Baltimore, MD: Lippincott Williams & Wilkins; 2012.

A. Characteristics of normal grief (bereavement) 1. Grie is ch aracterized in itially by shock an d denial. 2. In n orm al grie , th e b ereaved m ay exp erien ce an illusion (see Table 11.1) th at th e deceased p erson is p h ysically p resen t. 3. Norm al grie gen erally subsides after 1–2 years , alth ou gh som e eatu res m ay con tin u e lon ger. Even a ter th ey h ave su b sid ed, sym p tom s m ay retu rn on h olidays or sp ecial occasion s (th e “anniversary reaction”). 4. Th e mortality rate is h igh or close relatives (esp ecially widowed men) in th e irst year o b ereavem en t.

B. Physician’s response to death 1. Th e m ajor responsibility of the physician is to give su p p ort to th e dyin g p atien t an d th e p atien t’s am ily. 2. Gen erally, p h ysician s make the patient completely aware o th e d iagn osis an d p rogn osis. However, a p h ysician sh ou ld ollow th e p atien t’s lead as to h ow m u ch h e or sh e wan ts to kn ow abou t th e con dition . With th e p atien t’s p erm ission , th e physician may tell the family th e diagn osis an d oth er d etails o th e illn ess (see Ch ap ter 23). 3. Ph ysician s o ten eel a sense of failure at n ot p reven tin g th e death o a p atien t. Th ey m ay d eal with th is sen se by becom in g emotionally detached rom th e p atien t. Su ch detach m en t can p reclu de h elp in g th e p atien t an d am ily th rou gh th is im p ortan t tran sition .

Review Test Directions: Each o th e n u m b ered item s or in com p lete statem en ts in th is section is ollowed by an swers or by com p letion s o th e statem en t. Select th e one lettered an swer or com p letion th at is best in each case. 1. When question ed about her li estyle, a

4. A term in ally ill p atien t wh o u ses a

70-year-old wom an tells the doctor that she eats m ain ly sh an d chicken but en joys an occasion al steak. She also n otes that she is lactose in toleran t an d so avoids m ilk products but eats alm on ds, bean s, an d can n ed salm on with bon es daily. She also n otes that she drin ks on e cup o co ee an d on e glass o win e an d sm okes on e cigarette daily. To help preven t osteoporosis, the m ost im portan t advice the physician should give this patient is to

statem en t su ch as, “It is th e doctor’s ault th at I becam e ill; sh e didn’t do an electrocardiogram wh en I cam e or m y last o ce visit,” is m ost likely in wh ich stage o dyin g, accordin g to Elizabeth Kü b ler-Ross?

(A) (B) (C) (D)

stop drin kin g win e stop eatin g steak stop drin kin g co ee start u sin g d airy p rodu cts d esp ite h er in toleran ce (E) stop sm okin g

2. An 80-year-old wom an is bein g exam in ed by a p h ysician or ad m ission to a n u rsin g h om e. Th e wom an , wh o was brou gh t to th e doctor by h er son , seem s an xiou s an d con u sed. Th e m ost e ective action or th e p h ysician to take at th is tim e is to

(A) arran ge or im m ed iate ad m ission to a (B) (C) (D) (E)

n u rsin g h om e con d u ct a n eu rop sych ological evalu ation su ggest im m ed iate h osp italization ask th e son i h e h as ob served ch an ges in th e p atien t’s beh avior arran ge to exam in e th e wom an in h er own h om e

3. Each year d u rin g th e rst week in May, a 63-year-old wom an develop s ch est discom ort an d a eelin g o oreb odin g. Her h u sb an d died 5 years ago d u rin g th e rst week in May. Th is wom an’s exp erien ce is best describ ed as

(A) (B) (C) (D) (E)

an atten tion -seekin g d evice p ath ological grie an an n iversary reaction m alin gerin g dep ression

(A) (B) (C) (D) (E)

Den ial An ger Bargain in g Dep ression Accep tan ce

5. A p h ysician con d u cts a p h ysical exam in ation on an active, in dep en den t 75-year-old wom an . Wh ich o th e ollowin g n din gs is m ost likely?

(A) (B) (C) (D) (E)

In creased im m u n e resp on se In creased m u scle m ass Decreased size o brain ven tricles Decreased bladd er con trol Severe m em ory p roblem s

6. Nin ety p ercen t o th e p atien ts in a p rim ary care p h ysician’s p ractice are over 65 years o age. Wh en com p ared to th e gen eral p opu lation , th ese elderly p atien ts are m ore likely to sh ow wh ich o th e ollowin g p sych ological ch aracteristics?

(A) (B) (C) (D) (E)

Lower likelih ood o su icide Less an xiety Lower in telligen ce Poorer sleep qu ality Less dep ression

7. Th e 78-year-old h u sban d o a 70-yearold wom an h as ju st died . I th is wom an experien ces n orm al bereavem en t, wh ich o th e ollowin g resp on ses wou ld be exp ected?

(A) (B) (C) (D) (E)

In itial loss o ap p etite Feelin gs o worth lessn ess Th reats o su icide In ten se grie lastin g years a ter th e death Feelin gs o h op elessn ess

29

30

BRS Behavioral Science

8. A p h ysician h as ju st d iagn osed a case o

12. An 81-year-old p atien t com p lain s to

term in al p an creatic can cer in a 68-year-old m an . Wh ich o th e ollowin g statem en ts regardin g th e reaction s an d b eh avior o th e p h ysician is th e m ost tru e?

h is doctor th at h e som etim es h as trou b le allin g asleep an d wou ld like to h ave “a p ill to take” at th ose tim es. Ph ysical exam in ation is u n rem arkab le an d th e p atien t sh ows n o eviden ce o p sych op ath ology. O th e ollowin g agen ts, wh ich sh ou ld be avoided in th is p atien t?

(A) Sh e sh ou ld in orm th e am ily, bu t n ot th e (B) (C)

(D) (E)

p atien t, abou t th e seriou s n atu re o th e illn ess. Her in volvem en t with th e p atien t’s am ily sh ou ld en d wh en h e dies. Sh e sh ou ld p rovide stron g sedation or am ily m em bers wh en th e p atien t dies u n til th e in itial sh ock o h is death wears o . Sh e will eel th at sh e h as ailed wh en th e p atien t dies. Sh e will eel closer an d closer to th e p atien t as h is death ap p roach es.

9. Th e average d i eren ce in li e exp ectan cy

(A) (B) (C) (D) (E)

Dip h en h ydram in e Zalep lon Trazodon e Zolp id em Ram elteon

13. A 50-year-old wom an wh o is dyin g o can cer h as a 10-year-old son . Th e m oth er d oes n ot wan t th e ch ild to kn ow abou t h er illn ess or p rogn osis. Most correctly, with resp ect to th e m oth er’s con d ition , th e p h ysician sh ou ld

between Wh ite wom en an d A rican Am erican m en is ap p roxim ately

(A) talk to th e m oth er an d en cou rage h er to

(A) (B) (C) (D) (E)

(B)

3 years 6 years 10 years 15 years 20 years

(C) (D) (E)

tell h er son talk to th e son alon e an d tell h im abou t h is m oth er’s illn ess ollow th e m oth er’s wish es an d do n ot tell th e son talk to both th e m oth er an d son togeth er in sist th at th e m oth er tell h er son

10. Six m on th s a ter th e d eath o a loved on e, wh ich o th e ollowin g is m ost likely to in dicate th at a p erson is exp erien cin g a com p licated grie reaction ?

(A) (B) (C) (D) (E)

Lon gin g Cryin g Den ial th at th e loved on e h as died Irritab ility Illu sion s

11. An 80-year-old p atien t tells th e d octor th at sh e is con cern ed b ecau se sh e orgets th e add resses o p eop le sh e h as ju st m et an d takes lon ger th an in th e p ast to do th e Su n d ay crossword p u zzle. Sh e p lays card s regu larly with rien ds, is well groom ed , an d sh ops an d cooks or h ersel . Th is p atien t is p robab ly

(A) (B) (C) (D) (E)

sh owin g n orm al agin g sh owin g evid en ce o Alzh eim er’s d isease exp erien cin g d ep ression develop in g an an xiety d isorder u n ab le to live alon e

14. A 70-year-old p atien t wh ose wi e died 8 m on th s ago rep orts th at h e som etim es wakes u p an h ou r earlier th an u su al an d o ten cries wh en h e th in ks abou t h is wi e. He also tells you th at on on e occasion , h e b rief y ollowed a wom an down th e street wh o resem b led h is late wi e. Th e p atien t also relates th at h e h as rejoin ed h is bowlin g team an d en joys visits with h is gran dch ildren . For th is p atien t, th e b est recom m en d ation o th e p h ysician is

(A) m ed ication or sleep (B) evalu ation or m ajor dep ression (C) regu lar p h on e calls an d visits to “ch eck in” with th e doctor (D) p sych oth erapy (E) n eu rop sych ological evalu ation or Alzh eim er’s d isease

Chapter 3

15. An 85-year-old m an an d h is 80-yearold wi e are brou gh t to th e em ergen cy d ep artm en t a ter an au tom ob ile accid en t. Th e m an is d ead on arrival. Th e wom an is n ot seriou sly in ju red an d is con sciou s an d alert. Th e cou p le’s son h as been called an d is on h is way to th e h osp ital. Th e wom an asks th e p h ysician abou t h er h u sban d’s con dition . Most correctly, th e p h ysician sh ould tell h er

Aging, Death, and Bereavement

31

(A) n ot to worry bu t in stead to con cen trate (B) (C) (D) (E)

on h er own con dition th at h er h u sban d h as died an d th en stay an d o er su p p ort th at h er son is on th e way an d th at th ey will discu ss everyth in g wh en th e son arrives th at h e will ch eck on h er h u sban d’s con d ition a ter sh e is treated or h er in ju ries wh at h as h ap p en ed to h er bu t n ot wh at h as h ap p en ed to h er h u sban d

An swers an d Exp lan ation s

Typical Board Question The answer is B. Th is p atien t wh ose wi e died 8 m on th s ago sh ows evid en ce o a com p licated grie reaction . He is sh owin g sign s o dep ression (e.g., p oor groom in g, sign i ican t weigh t loss, seriou s sleep p roblem s, an d little in terest in in teractin g with rien ds an d am ily) (see Ch ap ter 12). Psych oth erapy, wh ile h elp u l, will b e less u se u l th an an tidep ressan t m edication or th is p atien t. His sleep will im p rove as th e d ep ression im p roves. Elderly p atien ts exp erien cin g dep ression o ten p resen t with m em ory p rob lem s th at m ay m im ic Alzh eim er’s disease (p seu dod em en tia). Th e su dden on set o m em ory p roblem s (e.g., orgettin g wh at h e h as been eatin g) with th e con cu rren t loss o h is wi e in d icates th at th e p atien t is likely to b e exp erien cin g d ep ression rath er th an Alzh eim er’s disease. Alth ou gh h e sh ou ld be closely ollowed, th ere is n o in dication at th is tim e th at th is p atien t n eed s a n eu rop sych iatric evalu ation .

1. The answer is E. Cigarette sm okin g, even i m od erate, is associated with th e develop m en t o osteop orosis. Alm on ds, bean s, an d can n ed salm on with bon es con tain calciu m an d th u s can h elp com p en sate or th e absen ce o d ietary d airy p rod u cts. Moderate in take o steak, co ee, an d alcoh ol as d escribed by th is p atien t are n ot associated with th e d evelop m en t or worsen in g o osteop orosis.

2. The answer is E. Th e m ost e ective action or th e p h ysician to take at th is tim e is to exam in e th e wom an in h er own h om e. An xiety or d ep ression at b ein g in an u n am iliar situ ation can lead to th e an xiety an d con u sion th at th is p atien t sh ows. Im m ediate adm ission to a n u rsin g h om e or h osp ital, or in terviewin g th e son are n ot ap p rop riate u n til a tru e p ictu re o th e p atien t’s con d ition h as b een ob tain ed . A n eu rop sych ological evalu ation also m ay n ot be h elp u l wh ile th is p atien t is sh owin g eviden ce o severe stress.

3. The answer is C. Th is wom an’s exp erien ce is b est described as an an n iversary reaction . In th is reaction , th e b ereaved p erson exp erien ces m an y o th e eelin gs sh e exp erien ced wh en h er h u sb an d died at sign i ican t tim es in su b sequ en t years. Th is is con sidered a n orm al reaction , n ot p ath ological grie , an d is n ot associated with dep ression . It is also n ot a sign o m alin gerin g or o seekin g atten tion .

4. The answer is B. Du rin g th e an ger stage o dyin g, th e p atien t is likely to blam e th e p h ysician .

5. The answer is D. O th e listed in d in gs, d ecreased bladd er con trol is th e m ost likely in din g in th e exam in ation o an active, in d ep en den t 75-year-old wom an . In agin g, im m u n e resp on ses an d m u scle m ass decrease an d b rain ven tricles in crease in size. Wh ile m ild m em ory p roblem s m ay occu r, severe m em ory p roblem s do n ot occu r in n orm al agin g. Severe m em ory p rob lem s th at in ter ere with n orm al u n ction in dicate th e develop m en t o a dem en tia su ch as Alzh eim er’s d isease.

6. The answer is D. Sleep d istu rban ces, su ch as d ecreased delta (slow wave) sleep (see Ch ap ter 10) com m on ly occu r in th e elderly. Su icide an d dep ression are m ore com m on in th e elderly th an in th e gen eral p op u lation . An xiety m ay arise easily d u e to ears o illn ess an d in ju ry. In telligen ce d oes n ot decrease in typ ical elderly p eop le.

7. The answer is A. In itial loss o ap p etite is com m on in n orm al bereavem en t. Feelin gs o worth lessn ess or h op elessn ess, th reats o su icide, an d an exten ded p eriod o grie ch aracterize d ep ression rath er th an n orm al b ereavem en t.

32

Chapter 3

Aging, Death, and Bereavement

33

8. The answer is D. Ph ysician s o ten eel th at th ey h ave ailed wh en a p atien t dies. Rath er th an becom in g closer, th is p h ysician m ay becom e em otion ally detach ed rom th e p atien t in order to deal with h is im p en din g death . Heavy sedation is rarely in dicated as treatm en t or th e bereaved becau se it m ay in ter ere with th e grievin g p rocess. Gen erally, p h ysician s in orm p atien ts wh en th ey h ave a term in al illn ess an d p rovide an im p ortan t sou rce o su p p ort or th e am ily be ore an d a ter th e p atien t’s death .

9. The answer is C. Th e di eren ce in li e exp ectan cy between Wh ite wom en (81.0 years) an d A rican -Am erican m en (71.4 years) is ap p roxim ately 10 years. Th e di eren ce in li e exp ectan cy by age an d sex is cu rren tly d ecreasin g.

10. The answer is C. Six m on th s a ter th e d eath o a loved on e, den yin g th at th e death h as actu ally occu rred su ggests a com p licated grie reaction . Norm ally, d en ial lasts u p to 24 h ou rs. Lon gin g, cryin g, irritability, an d illu sion s are all p art o a n orm al grie reaction .

11. The answer is A. Th is 80-year-old wom an is p robably sh owin g n orm al agin g, sin ce sh e can u n ction well livin g alon e. Min or m em ory loss th at d oes n ot in ter ere with n orm al u n ction in g su ch as sh e describes is typ ically seen in n orm ally agin g p eop le. Th ere is n o evid en ce th at th is p atien t h as Alzh eim er’s d isease, d ep ression , or an an xiety d isord er.

12. The answer is A. Th e an tih istam in ergic agen t dip h en h ydram in e (Ben adryl) sh ou ld be avoid ed in elderly p atien ts b ecau se it is likely to cau se sym p tom s o deliriu m . Un ortu n ately, a n u m b er o over-th e-cou n ter sleep m edicin es su ch as Tylen ol PM con tain dip h en h yd ram in e. Better ch oices or in som n ia in th e elderly in clu de n ewer sleep agen ts su ch as zolp id em (Am bien ) an d ram elteon (Rozerem ). Trazodon e is a sedatin g tricyclic an tid ep ressan t wh ich is also u se u l or occasion al p rob lem s allin g asleep in th e elderly.

13. The answer is A. It is u p to th e m oth er to d ecid e wh eth er, wh en , an d h ow to tell h er son abou t h er illn ess. However, sch ool-age ch ildren are o ten aware wh en som eth in g seriou s is goin g on with in th eir am ily an d can u n derstan d th e m ean in g o death (see Ch ap ter 2). Th ere ore, wh ile it is n ot ap p rop riate or th e p h ysician to in sist th at th e p atien t tell h er son , th e p h ysician sh ou ld talk to th e m oth er an d en cou rage h er to talk to h er son abou t h er term in al con dition . Th e p h ysician can also cou n sel th e p atien t on wh at to say to h er ch ild abou t h er im m in en t death .

14. The answer is C. Th is p atien t, wh ose wi e died 8 m on th s ago, is sh owin g a n orm al grie reaction . Alth ou gh h e som etim es wakes u p an h ou r earlier th an u su al an d cries wh en h e th in ks abou t h is wi e, h e is attem p tin g to retu rn to h is li estyle by rejoin in g h is bowlin g team an d visitin g with h is am ily. Th e illu sion o believin g h e sees an d th u s ollows a wom an wh o resem bled h is late wi e is seen in a n orm al grie reaction . For a n orm al grie reaction , recom m en din g regu lar p h on e calls an d visits to “ch eck in” with th e doctor is th e ap p rop riate in terven tion . Sleep m ed ication , an tidep ressan ts, p sych oth erapy, an d a n eu rop sych ological evalu ation are n ot n ecessary or th is p atien t at th is tim e.

15. The answer is B. Th ere is n o in d ication th at th is eld erly wom an is im p aired m en tally or p h ysically. Th ere ore, th e p h ysician sh ou ld tell h er th e tru th , th at is, th at h er h u sban d h as died an d th en stay an d o er su p p ort. As with all adu lt p atien ts, eld erly p atien ts sh ou ld b e told th e tru th . It is n ot n ecessary to wait or th e son to arrive, an d tellin g h er n ot to worry is p atron izin g.

c ha pte r

4

Gen etics, An atom y, an d Bioch em istry o Beh avior

Typical Board Question Wh en a 70-year-old m an wh o h as h ad a stroke attem p ts to (a) divide a lin e in h al , (b) tu rn sin gle lin es in to “Xs,” or (c) rep rod u ce a clock ace, h e does th e tasks like th is (see Figu re) e ectively n eglectin g th e le t o th e drawin gs. Th e area(s) o th e brain m ost likely to be a ected in th is p atien t is (are) th e

(A) (B) (C) (D) (E) (F)

righ t p arietal lob e basal gan glia h ip p ocam p u s reticu lar system am ygd ala le t ron tal lobe

(See “An sw ers an d Explan ation s” at th e en d of th e ch apter.)

(a )

(b) 12 1

(c)

11 10

2

9

3

4 5 6 87

I. THE GENETICS OF BEHAVIOR A. Studies for examining the genetics of behavior 1. Family risk studies com p are h ow requ en tly a beh avioral disord er or trait occu rs in th e relatives o th e a ected in d ivid u al (proband) with h ow requ en tly it occu rs in th e gen eral p op u lation .

2. Twin studies a. Adoption studies u sin g monozygotic twins or dizygotic twins reared in th e sam e or in di eren t h om es are u sed to di eren tiate th e e ects o gen etic actors rom en viron m en tal actors in th e occu rren ce o p sych iatric, su bstan ce abu se (e.g., alcoh olism ), an d n eu rop sych iatric d isorders. b. I th ere is a gen etic com p on en t to th e etiology, a disorder m ay be exp ected to h ave a h igh er concordance rate in m on ozygotic twin s th an in d izygotic twin s (i.e., i con cord an t, th e d isorder occu rs in b oth twin s). 3. It h as b een di icu lt to lin k p articu lar ch rom osom es with p sych iatric illn esses. However, in a n u m ber o stu dies over years, su ch association s h ave been m ade. a. Schizophrenia (Ch ap ter 11) h as b een associated with m arkers on ch rom osom es 1, 6, 7, 8, 13, 21, an d 22. b. Bipolar disorder an d major depressive disorder (Ch ap ter 12) recen tly h ave been associated with m arkers on ch rom osom es 3, 5 an d 6.

B. Specific chromosomes h ave been associated with oth er disorders with beh avioral sym p tom s (Table 4.1).

34

Chapter 4

t a b l e Chromosome

4.1

Genetics, Anatomy, and Biochemistry of Behavior

35

Chromosomal Disorders with Behavioral Manifestations

Disorder

Behavioral Manifestations

1

Alzheimer’s disease

Depression, anxiety, dementia (early onset)

4

Huntington’s disease

Erratic behavior, psychiatric symptoms (e.g., depression, psychosis), dementia

5

Sotos syndrome

Intellectual impairment, phobias, hyperphagia

7

William’s syndrome

Hypersociality, intellectual disability, behavioral problems, hypotonia

8

Cohen’s syndrome

Autistic behavior, intellectual disability

9

Dystonia musculorum deformans (DYT1) Tuberous sclerosis

Depression, learning problems Seizures, cognitive impairment, autistic behavior

11

Acute intermittent porphyria

Manic behavior, psychosis (see Chapter 5)

12

Phenylketonuria

Attention deficit hyperactivity disorder (ADHD), intellectual disability

13

Wilson’s disease

Depression, personality changes, psychotic symptoms

14

Alzheimer’s disease

Depression, anxiety, dementia (early onset)

15

Chromosome 15 inversion-duplication syndrome Prader-Willi syndrome/Angelman syndrome

Seizures, autistic behavior, hypotonia

16

Tuberous sclerosis

Seizures, cognitive impairment, autistic behavior

17

Neurofibromatosis-1 Charcot-Marie-Tooth disease Smith-Magenis syndrome

Cognitive impairment Peripheral neuropathy Intellectual disability, impaired expressive language, stereotyped behavior, clinging and dependency, seizures

18

Tourette’s disorder

Dyscontrol of language and movements

19

Alzheimer’s disease (site of the APO E4 gene)

Depression, anxiety, dementia (at the typical age of onset)

21

Progressive myoclonic epilepsy Alzheimer’s disease (associated with Down’s syndrome)

Cognitive regression, aphasia, intellectual disability Depression, anxiety, dementia (early onset)

22

Metachromatic leukodystrophy Neurofibromatosis-2 DiGeorge/velocardiofacial syndrome

Personality changes, psychosis, dementia Hearing impairment Schizophrenia, bipolar disorder, psychomotor retardation, language delay, ADHD, seizures

X

Fragile X syndrome Kallmann’s syndrome Lesch-Nyhan syndrome Rett’s disorder

Autistic behavior, intellectual disability Anosmia, lack of sex drive, depression, anxiety, fatigue, insomnia Self-mutilation and other bizarre behavior, intellectual disability Autistic behavior, hand-wringing, breathing abnormalities

Intellectual disability, rage, stubbornness, rigid thinking, and self-injury

Adapted from Fadem B, Monaco E. High Yield Brain and Behavior. Baltimore, MD: Lippincott Williams & Wilkins; 2007:27, with permission.

II. THE NEUROANATOMY OF BEHAVIOR Th e h u m an n ervou s system con sists o th e central nervous system (CNS) an d th e peripheral ner-

vous system (PNS). A. Th e CNS con tain s th e brain an d sp in al cord. 1. Th e cerebral cortex can be divided a. Anatomically in to at least ou r sets o lobes: ron tal, tem p oral, p arietal, an d occip ital, as well as th e lim b ic lobes (wh ich con tain m edial p arts o th e ron tal, tem p oral, an d p arietal lobes an d in clu de th e h ip p ocam p u s, am ygdala, orn ix, sep tu m , p arts o th e th alam u s, an d cin gu late gyru s an d related stru ctu res). b. By arrangement o n eu ron layers or cytoarch itectu re. c. Functionally in to m otor, sen sory, an d association areas.

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BRS Behavioral Science

2. Th e cerebral h em isp h eres. a. Th e h em isp h eres are connected by th e corp u s callosu m , an terior com m issu re, h ip p ocam p al com m issu re, an d h aben u lar com m issu re. b. Th e u n ction s o th e h em isp h eres are lateralized. (1) Th e right, or nondominant, hemisphere is associated p rim arily with perception; it is also associated with spatial relations , body image , an d m u sical an d artistic ability. (2) Th e left, or dominant, hemisphere is associated with language function in ab ou t alm ost all righ t-h an ded p eop le an d m ost le t-h an ded p eop le. c. Sex differences in cerebral lateralization . Women m ay h ave a larger corp u s callosu m an d an terior com m issu re an d ap p ear to h ave better in terh em isp h eric com m u n ication th an m en . Men m ay h ave b etter-develop ed righ t h em isp h eres an d ap p ear to be m ore adep t at sp atial tasks th an wom en . 3. Brain lesions cau sed by acciden t, d isease, su rgery, or oth er in su lt are associated with p articu lar n eu rop sych iatric e ects (Table 4.2).

4. Memory systems a. Exp licit or declarative memory in volves th e kn owledge o acts an d is retrieved consciously. b. Im p licit or nondeclarative memory in volves in orm ation on h ow to p er orm an act an d is recalled unconsciously. c. Th e n eu roan atom y o th ese m em ory system s an d clin ical exam p les can be ou n d in Table 4.3.

B. Th e PNS con tain s all sensory, motor, and autonomic ib ers ou tsid e o th e CNS, in clu d in g th e spinal nerves, cranial nerves , an d peripheral ganglia . 1. Th e PNS ca rries sensory in orm a tio n to th e CNS a n d motor in orm a tio n awa y rom th e CNS.

t a b l e

4.2

Neuropsychiatric Effects of Brain Lesions on Behavior

Location of Lesion

Effects

Frontal lobes

Mood changes (e.g., depression with dominant lesions, mood elevation with nondominant lesions) Difficulties with motivation, concentration, attention, orientation, and problem solving (dorsolateral convexity lesions) Difficulties with judgment, inhibitions, emotions, personality changes (orbitofrontal lesions) Inability to speak fluently (i.e., Broca aphasia [dominant lesions])

Temporal lobes

Impaired memory Psychomotor seizures Changes in aggressive behavior Inability to understand language (i.e., Wernicke’s aphasia [dominant lesions])

Limbic lobes

Poor new learning; implicated specifically in Alzheimer’s disease

Hippocampus

Klüver-Bucy syndrome (decreased aggression, increased sexual behavior, hyperorality)

Amygdala

Decreased conditioned fear response Problems recognizing the meaningfulness of facial and vocal expressions of anger in others

Parietal lobes

Impaired processing of visual–spatial information (e.g., cannot copy a simple line drawing or neglects the numbers on the left side when drawing a clock face [right-sided lesions]) Impaired processing of verbal information (e.g., cannot tell left from right, do simple math, name fingers, or write [Gerstmann’s syndrome, dominant lesions])

Occipital lobes

Visual hallucinations and illusions Inability to identify camouflaged objects Blindness

Hypothalamus

Hunger leading to obesity (ventromedial nucleus damage), loss of appetite leading to weight loss (lateral nucleus damage) Effects on sexual activity and body temperature regulation

Reticular system

Changes in sleep–wake mechanisms (e.g., decreased REM sleep) Loss of consciousness

Basal ganglia

Disorders of movement (e.g., Parkinson’s disease [substantia nigra], Huntington’s disease [caudate and putamen], and Tourette’s syndrome [caudate])

Chapter 4 t a b l e

4.3

Genetics, Anatomy, and Biochemistry of Behavior

37

Memory Systems and Associated Neuroanatomy

Type of System

Type of Memory

Associated Anatomy

Length of Recall

Memory Used to Remember

Declarative (explicit or conscious)

Episodic

Temporal lobes (medial), anterior thalamic nuclei, fornix, hippocampus, mammillary bodies, prefrontal cortex Inferolateral temporal lobes

Long term

Personally experienced events, e.g., what you ate yesterday

Long term

General knowledge about the world, e.g., the capital of New J ersey Things you do automatically, e.g., how to tie your shoes Recent information, e.g., the phone number just obtained from a new acquaintance

Semantic

Nondeclarative (implicit or unconscious)

Procedural

Cerebellum, basal ganglia, supplementary motor area

Long term

Working

Prefrontal cortex, language and visual association areas

Short term

2. Th e au ton om ic n ervou s system , wh ich con sists o sympathetic an d parasympathetic division s, in n ervates th e in tern al organ s. 3. Th e au ton om ic n ervou s system coord in ates em otion s with visceral resp on ses su ch as h eart rate, blood p ressu re, an d p ep tic acid secretion . 4. Visceral resp on ses occu rrin g as a resu lt o psychological stress are in volved in th e develop m en t an d exacerb ation o som e physical illnesses (see Ch ap ter 22).

III. NEUROTRANSMISSION A. Synapses and neurotransmitters 1. In orm ation in th e n ervou s system is tran s erred across th e synaptic cleft (i.e., th e sp ace b etween th e axon term in al o th e p resyn ap tic n eu ron an d th e den drite o th e p ostsyn ap tic n eu ron ). 2. Wh en th e p resyn ap tic n eu ron is stim u lated, a neurotransmitter is released, travels across th e syn ap tic cle t, an d acts on recep tors on th e p ostsyn ap tic n eu ron . Neu rotran sm itters are excitatory i th ey in crease th e ch an ces th at a n eu ron will ire an d inhibitory i th ey decrease th ese ch an ces.

B. Presynaptic and postsynaptic receptors are p rotein s p resen t in th e m em bran e o th e n eu ron th at can recogn ize sp eci ic n eu rotran sm itters. 1. Th e changeability o n u m ber or a in ity o recep tors or sp eci ic n eu rotran sm itters (neuronal plasticity) can regu late th e resp on siven ess o n eu ron s. 2. Second messengers. Wh en stim u lated by n eu rotran sm itters, p ostsyn ap tic recep tors m ay alter th e m etabolism o n eu ron s by th e u se o secon d m essen gers, wh ich in clu de cyclic adenosine monophosphate (cAMP), lipids (e.g., diacylglycerol), Ca 2+, an d nitric oxide . C. Classification of neurotransmitters. Biogenic amines (m on oam in es), amino acids , an d peptides are th e th ree m ajor classes o n eu rotran sm itters. D. Regulation of neurotransmitter activity 1. Th e con cen tration o n eu rotran sm itters in th e syn ap tic cle t is closely related to m ood an d b eh avior. A n u m ber o m ech an ism s a ect th is con cen tration . 2. A ter release by th e p resyn ap tic n eu ron , n eu rotran sm itters are rem oved rom th e syn ap tic cle t by m ech an ism s in clu d in g: a. Reuptake by th e p resyn ap tic n eu ron . b. Degradation by en zym es su ch as monoamine oxidase (MAO).

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t a b l e

4.4

Psychiatric Conditions and Associated Neurotransmitter Activity

Neuropsychiatric Condition

Neurotransmitter Activity Increased (↑ ) or Decreased (↓ )

Depression

Norepinephrine (↓ ), serotonin (↓ ), dopamine (↓)

Mania

Dopamine (↑), g-aminobutyric acid (GABA) (↓)

Schizophrenia

Dopamine (↑ ), serotonin (↑ ), glutamate (↑ or ↓ )

Anxiety

GABA (↓ ), serotonin (↓ ), norepinephrine (↑ )

Alzheimer’s disease

Acetylcholine (↓ ), glutamate (↑ )

3. Availability o sp eci ic n eu rotran sm itters is associated with com m on psychiatric con dition s (Table 4.4). Norm alization o n eu rotran sm itter availability by pharm acological agen ts is associated with sym p tom im p rovem en t in th ese disorders (see Chap ter 16).

IV. BIOGENIC AMINES A. Overview 1. Th e biogenic amines , or monoamines , in clu de catech olam in es, in dolam in es, eth yl am in es, an d qu atern ary am in es. 2. Th e monoamine theory of mood disorder h yp oth esizes th at lowered monoamine activity results in depression and elevated levels in mania . 3. Metabolites o the m onoam ines are o ten m easured in psychiatric research and diagnosis because they are m ore easily m easured in body luids than the actual m onoam ines (Table 4.5). 4. Distrib u tion o d op am in ergic, n orad ren ergic, an d seroton ergic tracts in th e CNS can be ou n d in Figu re 4.1.

B. Dopamine 1. Dop am in e, a catech olam in e, is in volved in th e p ath op h ysiology o schizophrenia an d other psychotic disorders, Parkinson’s disease, mood disorders , th e con dition ed ear resp on se (see Ch ap ter 7), an d th e “rewardin g” n atu re o certain d ru gs (see Ch ap ter 9). 2. Synthesis. Th e am in o acid tyrosin e is con verted to th e p recu rsor or dop am in e by th e en zym e tyrosine hydroxylase . 3. Receptor subtypes. At least ive d op am in e recep tor su btyp es (D 1–D 5) h ave been iden ti ied; th e m ajor site o action is D 2 or tradition al an tip sych otic agen ts an d D 1 an d D 4 as well as D 2 or th e n ewer “atyp ical” an tip sych otic agen ts (see Ch ap ter 16).

t a b l e

4.5

Metabolites of Monoamines and Associated Psychopathology

Increased (↑) or Decreased (↓) Concentration of Metabolite in Blood Plasma, Cerebrospinal Neurotransmitter Fluid, or Urine Dopamine

(↑ ) HVA (homovanillic acid)

Associated Psychopathology

(↓ ) HVA

Schizophrenia and other conditions involving psychosis (see Chapters 9, 11, and 12) Parkinson’s disease Treatment with antipsychotic agents Depression

Norepinephrine

(↑ ) VMA (vanillylmandelic acid) (↓ ) MHPG (3-methoxy-4-hydroxyphenylglycol)

Adrenal medulla tumor (pheochromocytoma) Severe depression and attempted suicide

Serotonin

(↓ ) 5-HIAA (5-hydroxyindoleacetic acid)

Severe depression and attempted suicide Aggressiveness and violence Impulsiveness Tourette’s syndrome Alcohol misuse Bulimia

Chapter 4

Genetics, Anatomy, and Biochemistry of Behavior Tube roinfundibula r tra ct

S tria tum Nigros tria ta l tra ct

Me s olimbic/ me s ocortica l tra ct

Fornix Ve ntra l te gme nta l a re a

Orbitofronta l corte x S e pta l nucle i

S ubs ta ntia nigra

Nucle us a ccumbe ns

OH

H H

HO

C

Amygda la

C

P ons

NH2

H H Dopa mine

A

Ce re be llum

Me dulla

Ce rulocortica l tra ct

Fornix Locus ce rule us Amygda la Hippoca mpus

OH

OH H

HO

C

C

NH2

H H Nore pine phrine

B

Ra phe cortica l tra ct

Fornix

Amygda la Hippoca mpus HO

C N

C

Ra phe nucle i

H H C

NH2

H H

S e rotonin

FIGURE 4.1. Distribution of (A) dopaminergic, (B) noradrenergic, and (C) serotonergic tracts in the CNS.

39

40

BRS Behavioral Science

4. Dopaminergic tracts (Figure 4.1A) a. Th e nigrostriatal tract is in volved in th e regu lation o m u scle ton e an d m ovem en t. (1) Th is tract degenerates in Parkinson’s disease. (2) Treatm en t with an tip sych otic d ru gs, wh ich block p ostsyn ap tic dop am in e recep tors receivin g in p u t rom th e n igrostriatal tract, can resu lt in Parkin son -like sym p tom s. b. Dop am in e acts on th e tuberoinfundibular tract to in h ib it th e secretion o p rolactin rom th e an terior p itu itary. (1) Blockad e o d op am in e recep tors by an tip sych otic dru gs p reven ts th e in h ibition o p rolactin release an d resu lts in elevated prolactin levels. (2) Th is elevation in tu rn resu lts in sym p tom s su ch as breast en largem en t, galactorrh ea, an d sexu al dys u n ction . c. Th e mesolimbic–mesocortical tract is associated with p sych otic disorders. (1) Th is tract m ay h ave a role in th e exp ression o emotions sin ce it p rojects in to th e lim bic system an d p re ron tal cortex. (2) Hyp eractivity o th e m esolim bic tract is associated with the p ositive sym p tom s (e.g., h allu cin ation s) o sch izop h ren ia; h yp oactivity o the m esocortical tract is associated with th e n egative sym p tom s (e.g., ap ath y) o sch izop hren ia (see Ch ap ter 11).

C. Norepinephrine, a catech olam in e, p lays a role in mood, anxiety, arousal, learning, an d memory. 1. Synthesis a. Like dop am in ergic n eu ron s, n oradren ergic n eu ron s syn th esize dop am in e. b. Dop am in e β-h yd roxylase, p resen t in n oradren ergic n eu ron s, con verts th is dop am in e to n orep in ep h rin e. 2. Localization. Most n oradren ergic n eu ron s (ap p roxim ately 10,000 p er h em isp h ere in th e brain ) are located in th e locus ceruleus (Figure 4.1B).

D. Serotonin, an in dolam in e, p lays a role in mood, sleep, sexuality, an d impulse control. Elevation o seroton in is associated with im p roved m ood an d sleep but decreased sexu al u n ction (p articu larly delayed orgasm ). Very h igh levels are associated with psychotic symptoms (see Ch ap ter 11). Decreased seroton in is associated with poor im pulse con trol, dep ression , an d poor sleep. 1. Synthesis. The am ino acid tryptophan is converted to serotonin (also known as 5-hydroxytryptamine [5-HT]) by the enzym e tryptophan hydroxylase as well as by an am in o acid decarboxylase. 2. Localization. Most seroton ergic cell bodies in th e brain are con tain ed in th e dorsal raphe nucleus in the upper pons and lower midbrain (Figure 4.1C). 3. Antidepressants and serotonin. Heterocyclic an tidep ressan ts (HCAs ), selective seroton in an d seroton in an d n orep in ep h rin e reu p take in h ib itors (SSRIs an d SNRIs ), an d m on oam in e oxidase in h ibitors (MAOIs ) u ltim ately in crease th e p resen ce o seroton in an d n orep in ep h rin e in th e syn ap tic cle t (Ch ap ter 16). a. HCAs an d SNRIs block reu p take o seroton in an d n orep in ep h rin e, an d SSRIs su ch as lu oxetin e (Prozac) selectively block reu p take o seroton in by th e p resyn ap tic n eu ron . b. MAOIs p reven t th e d egrad ation o seroton in an d n orep in ep h rin e by MAO.

E. Histamine 1. Histam in e, an ethylamine , is a ected by p sych oactive dru gs. 2. Histam in e recep tor b lockade with dru gs su ch as an tip sych otics an d tricyclic an tidep ressan ts is associated with com m on sid e e ects o th ese d ru gs su ch as sedation an d increased appetite lead in g to weigh t gain . F. Acetylcholine (Ach), a qu atern ary am in e, is th e tran sm itter u sed by nerve–skeleton–muscle junctions . 1. Degeneration of cholinergic neurons is associated with Alzheimer’s disease, Down’s syndrome, an d movement and sleep disorders (e.g., d ecreased REM sleep, see Ch ap ter 10). 2. Cholinergic neurons syn th esize Ach rom acetyl coen zym e A an d ch olin e u sin g th e en zym e choline acetyltransferase . 3. Th e nucleus basalis of Meynert is a brain area in volved in p rodu ction o Ach . 4. Acetylcholinesterase (Ach E) breaks Ach down in to ch olin e an d acetate.

Chapter 4

Genetics, Anatomy, and Biochemistry of Behavior

41

5. Blockin g th e action o AchE with d ru gs su ch as donepezil (Aricep t), rivastigmine (Exelon ), an d galantamine (Rem in yl) m ay delay th e p rogression o Alzh eim er’s disease bu t can n ot reverse th e u n ction alread y lost.

6. Blockade of muscarinic Ach receptors with dru gs su ch as an tip sych otics an d tricyclic an tidep ressan ts resu lts in th e classic “an tich olin ergic” adverse e ects seen with th e u se o th ese dru gs, in clu din g dry m ou th , blu rred vision , u rin ary h esitan cy, an d con stip ation . Use o th ese agen ts can also resu lt in cen tral an tich olin ergic e ects su ch as con u sion an d m em ory p rob lem s. 7. An tich olin ergic agen ts are com m on ly u sed to treat th e Parkin son -like sym p tom s cau sed by an tip sych otic agen ts (see Section IV.B.4.a. above).

V. AMINO ACID NEUROTRANSMITTERS Th ese n eu rotran sm itters are in volved in m ost syn ap ses in th e brain an d in clu de glutamate, γ-aminobutyric acid (GABA), and glycine .

A. Glutamate 1. Glu tam ate is an excitatory n eu rotran sm itter th at con tribu tes to th e p ath op h ysiology o neurodegenerative illnesses su ch as Alzh eim er’s d isease an d sch izop h ren ia. a. Th e m ech an ism o th is association in volves activation o th e glu tam ate recep tor N-methyl-d -aspartate (NMDA) by su stain ed elevation o glu tam ate. b. Su ch activation resu lts in calciu m ion s en terin g n eu ron s leadin g to n erve cell degen eration an d d eath th rou gh excitotoxicity. c. Memantine (Nam en d a), an NMDA recep tor an tagon ist, u ltim ately blocks this influx of calcium an d is in dicated or p atien ts with m oderate to severe Alzheimer’s d isease. B. GABA 1. GABA is th e p rin cip al inhibitory n eu rotran sm itter in th e CNS. It is syn th esized rom glu tam ate by th e en zym e glu tam ic acid d ecarboxylase, wh ich n eed s vitam in B6 (pyrid oxin e) as a co actor. 2. GABA is closely in volved in th e action o an tian xiety agen ts su ch as benzodiazepines (e.g., d iazep am [Valiu m ]) an d barbiturates (e.g., secobarb ital [Secon al]). Ben zodiazep in es an d b arb itu rates in crease th e a in ity o GABA or its GABAA-binding site , allowin g m ore ch lorid e to en ter th e n eu ron . Th e ch lorid e-laden n eu ron s b ecom e h yp erp olarized an d in h ibited , d ecreasin g n eu ron al irin g an d u ltim ately decreasin g an xiety. An ticon vu lsan ts also p oten tiate th e activity o GABA.

C. Glycine is an in h ibitory n eu rotran sm itter ou n d p rim arily in th e sp in al cord. Glycin e works on its own an d as a regu lator o glu tam ate activity.

VI. NEUROPEPTIDES A. Endogenous opioids such as enkephalins, endorphins, dynorphins, and endomorphins are p rod u ced by th e b rain itsel . Th ey act to d ecrease p ain an d an xiety an d h ave a role in addiction an d m ood.

B. Placebo effects (see Ch ap ter 25) m ay b e m ediated by th e en d ogen ou s op ioid system . For exam p le, p rior treatm en t with an op ioid recep tor blocker su ch as n aloxon e can b lock p laceb o e ects.

Review Test Directions: Each o th e n u m bered item s or in com p lete statem en ts in th is section is ollowed by an swers or by com p letion s o th e statem en t. Select th e one lettered an swer or com p letion th at is best in each case. 1. A 45-year-old m ale p atien t b ecom es

4. A 65-year-old em ale p atien t h as h ad a

dep ressed ollowin g a h ead in ju ry. Th e area(s) o th e brain m ost likely to b e a ected in th is p atien t is (are) th e

stroke a ectin g th e le t h em isp h ere o h er brain . Wh ich o th e ollowin g u n ction s is m ost likely to b e a ected by th e stroke? (A) Percep tion (B) Mu sical ability (C) Sp atial relation s (D) Lan gu age (E) Artistic ab ility

(A) (B) (C) (D) (E) (F)

righ t p arietal lob e basal gan glia h ip p ocam p u s reticu lar system am ygd ala le t ron tal lobe

2. A 43-year-old m an p resen ts to th e em ergen cy d ep artm en t o a large h osp ital. He is very an xiou s an d com p lain s o abdom in al cram p s an d diarrh ea. Th e p h ysician observes in ten se u sh in g o th e m an’s skin . In th is p atien t, a 24-h ou r u rin e stud y is m ost likely to reveal elevated levels o

(A) acetylch olin e (B) 5-h ydroxyin d oleacetic acid (5-HIAA) (C) glycin e (D) van illylm an delic acid (VMA) (E) h om ovan illic acid (HVA)

3. In a clin ical exp erim en t, a 48-year-old em ale p atien t with ch ron ic p ain wh o, in th e p ast, h as resp on d ed to p laceb os is given n aloxon e. Sh ortly th erea ter th e p atien t is given an in ert su b stan ce th at sh e b elieves is a p ain killer. A ter th e p a tien t receives th e in ert su b stan ce, h er p a in is m ost likely to

(A) (B) (C) (D)

in crease decrease be u n ch an ged resp on d to lower doses o op ioids th an p reviou sly (E) ail to resp on d to op ioids in th e u tu re

42

5. Wh ich o th e ollowin g two stru ctu ral en tities con n ect th e cerebral h em isp h eres?

(A) (B) (C) (D)

Basal gan glia an d an terior com m issu re An terior com m issure an d reticular system Reticu lar system an d corp u s callosu m Hip p ocam p al com m issu re an d corp u s callosu m (E) Am ygdala an d h ab en u lar com m issu re

6. A 23-year-old p atien t sh ows side e ects su ch as sed ation , in creased ap p etite, an d weigh t gain wh ile bein g treated with an tip sych otic m edication . O th e ollowin g, th e m ech an ism m ost closely associated with th ese e ects is

(A) (B) (C) (D) (E)

blockad e o seroton in recep tors blockad e o d op am in e recep tors blockad e o n orep in ep h rin e recep tors blockad e o h istam in e recep tors decreased availability o seroton in

7. A 3-year-old girl wh o h ad been develop in g typically sin ce birth begin s to with draw socially an d th en stop s sp eakin g altogeth er. Also, in stead o p u rp ose u l h an d m ovem en ts, th e ch ild h as begu n to sh ow rep etitive h an d wrin gin g beh avior. Th e ch rom osom e m ost likely to be in volved in th is disorder is ch rom osom e

(A) (B) (C) (D) (E)

1 16 18 21 X

Chapter 4

Genetics, Anatomy, and Biochemistry of Behavior

8. Th e m ajor n eu rotran sm itter im p licated in both Alzh eim er’s disease an d sch izop h ren ia is (A) seroton in (B) n orep in ep h rin e (C) dop am in e (D) γ-am in obu tyric acid (GABA) (E) acetylch olin e (Ach ) (F) glu tam ate 9. Th e m ajor n eu rotran sm itter in volved in th e an tidep ressan t action o (Prozac) is

(A) (B) (C) (D) (E) (F)

u oxetin e

seroton in n orep in ep h rin e dop am in e γ-am in obu tyric acid (GABA) acetylch olin e (Ach ) glu tam ate

10. Th e n eu rotran sm itter m etabolized to 5-HIAA (5-h yd roxyin doleacetic acid) is

(A) (B) (C) (D) (E) (F)

seroton in n orep in ep h rin e dop am in e γ-am in obu tyric acid (GABA) acetylch olin e (Ach ) glu tam ate

11. A 25-year-old m ale p atien t su stain s a seriou s h ead in ju ry in an au tom obile acciden t. He h ad b een aggressive an d assau ltive, b u t a ter th e accid en t, h e is p lacid an d coop erative. He also m akes in ap p rop riate su ggestive com m en ts to th e n u rses an d m astu rb ates a great d eal. Th e area(s) o th e brain m ost likely to be in ju red in th is p atien t is (are) th e

(A) (B) (C) (D) (E) (F)

righ t p arietal lob e basal gan glia h ip p ocam p u s reticu lar system am ygd ala le t ron tal lobe

13. A 55-year-old wom an was diagn osed with sch izop h ren ia at th e age o 22. I th is diagn osis was ap p rop riate, th e volu m e o th e h ip p ocam p u s, th e size o th e cereb ral ven tricles, an d glu cose u tilization in th e ron tal cortex o th is p atien t are n ow m ost likely to b e, resp ectively

(A) (B) (C) (D) (E)

in creased, in creased, in creased decreased , decreased , d ecreased decreased , decreased , in creased decreased , in creased , decreased in creased, decreased, in creased

14. An 80-year-old em ale p atien t h as a restin g trem or o h er le t h an d, little exp ression in h er ace, an d p roblem s takin g a f rst step wh en sh e h as been stan din g still. Th e area(s) o th e brain m ost likely to b e a ected in th is p atien t is (are) th e

(A) (B) (C) (D) (E) (F)

righ t p arietal lob e basal gan glia h ip p ocam p u s reticu lar system am ygd ala le t ron tal lobe

Questions 15 and 16 A 69-year-old orm er ban k p residen t can n ot tell you th e n am e o th e cu rren t p resid en t an d h as d i icu lty id en ti yin g th e wom an sittin g n ext to h im (h is wi e). He b egan h avin g m em ory p roblem s 3 years ago.

15. Atrop h y o wh ich area(s) o th e brain is (are) m ost likely to b e seen in th is p atien t?

(A) (B) (C) (D) (E) (F)

righ t p arietal lob e basal gan glia h ip p ocam p u s reticu lar system am ygd ala le t ron tal lobe

16. Th e p ostm ortem brain biop sy o th is

12. A 35-year-old em ale p atien t rep orts

p atien t is m ost likely to sh ow

th at sh e h as d i f cu lty sleep in g ever sin ce sh e su stain ed a con cu ssion in a su bway acciden t. Th e area(s) o th e brain m ost likely to be a ected in th is p atien t is (are) th e

(A) in creased 3-m eth oxy-4-

(A) (B) (C) (D) (E) (F)

righ t p arietal lob e basal gan glia h ip p ocam p u s reticu lar system am ygd ala le t ron tal lobe

43

(B) (C) (D) (E)

h ydroxyp h en ylglycol (MHPG) righ t ron tal h yp ertrop h y decreased calciu m levels decreased h om ovan illic acid (HVA) dep osition o β-am yloid

44

BRS Behavioral Science

17. A 28-year-old m ale p atien t is brou gh t to

20. A 24-year-old m an su stain s a h ead in ju ry

th e em ergen cy room a ter a f gh t in wh ich h e attacked a m an wh o cu t in to h is lin e at th e su p erm arket ch eckou t. In th e em ergen cy room , h e rem ain s assau ltive an d com b ative. Th e bod y u ids o th is p atien t are m ost likely to sh ow (A) in creased 3-m eth oxy-4h ydroxyp h en ylglycol (MHPG) (B) decreased MHPG (C) in creased 5-h yd roxyin doleacetic acid (5-HIAA) (D) decreased 5-HIAA (E) decreased h om ovan illic acid (HVA)

in an au tom obile accid en t. His ath er relates th at p rior to th e accid en t, th e p atien t was resp ect u l, m od est, con trolled , an d h ard workin g. In th e h osp ital, th e p atien t is ru d e to th e n u rses an d aides, loses h is tem p er with th e sligh test p rovocation , an d re u ses to wear a h osp ital gown or an yth in g else. Th ese beh avioral ch an ges a ter th e accid en t in d icate th at th e area o th e b rain m ost likely to h ave been in ju red in th is p atien t is th e (A) dorsolateral con vexity o th e ron tal lobe (B) h yp oth alam u s (C) orb ito ron tal cortex (D) reticu lar system (E) am ygd ala (F) n u cleu s basalis o Meyn ert

18. A 30-year-old wom an wh o is with d rawin g rom h eroin sh ows in ten se an xiety, in creased p u lse, elevated blood p ressu re, an d a h an d trem or. Her sym p tom s im p rove wh en sh e is given clon id in e, an alp h a 2-adren ergic recep tor agon ist. Th e area(s) o th e brain m ost likely to b e in volved in th e im p rovem en t in th is p atien t’s sym p tom s is (are) th e

(A) (B) (C) (D) (E) (F)

righ t p arietal lob e basal gan glia locu s ceru leu s rap h e n u clei am ygd ala su b stan tia n igra

19. A very an xiou s 25-year-old p atien t is exam in ed in th e em ergen cy room . Th ere is n o eviden ce o p h ysical illn ess. I it cou ld be m easu red, th e γ-am in obu tyric acid (GABA) activity in th e b rain o th is p atien t wou ld m ost likely be

(A) (B) (C) (D) (E)

in creased decreased u n ch an ged h igh er th an th e activity o seroton in h igh er th an th e activity o dop am in e

21. An alysis o th e b lood p lasm a o a 45-year-old m ale p atien t sh ows in creased con cen tration o h om ovan illic acid (HVA). Th is elevation is m ost likely to be associated with wh ich o th e ollowin g con d ition s?

(A) (B) (C) (D) (E)

Parkin son’s disease Dep ression Bu lim ia Ph eoch rom ocytom a Sch izop h ren ia

22. Rem em b erin g th at sch ool closes early b e ore Th an ksgivin g Day every year is an exam p le o wh ich o th e ollowin g typ es o m em ory?

(A) (B) (C) (D)

Sem an tic Ep isodic Proced u ral Workin g

23. A 55-year-old p atien t wh o is takin g tiotrop iu m brom ide (Sp iriva) or ch ron ic obstru ctive p u lm on ary disease h as m em ory p roblem s d u e to th e agen t’s action on wh ich o the ollowin g recep tors?

(A) (B) (C) (D) (E)

Adren ergic Ch olin ergic Dop am in ergic Histam in ergic Seroton ergic

Chapter 4

Genetics, Anatomy, and Biochemistry of Behavior

45

24. A 6-year-old ch ild sh ows seizu res,

26. A 30-year-old m an wh o h as h ad m an y

cogn itive d e ects, an d au tistic b eh avior. Th e ch ild also sh ows raised discolored areas on h er oreh ead ( oreh ead p laqu es). Wh ich o th e ollowin g ch rom osom es is m ost likely to be in volved in th e etiology o th is ch ild’s sym p tom s?

n egative li e exp erien ces becom es u p set wh en h e sees p h otograp h s o h im sel taken du rin g th ese tim es. Th e brain area m ost likely to be activated by th ese p h otograp h s is th e

(A) (B) (C) (D) (E)

1 16 18 21 X

(A) (B) (C) (D) (E) (F)

dorsolateral con vexity o th e ron tal lobe h yp oth alam u s orb ito ron tal cortex reticu lar system am ygd ala n u cleu s basalis o Meyn ert

25. A 72-year-old m an with Alzh eim er’s

27. Th e brain p ath way m ost closely

d isease is b ein g treated with m em an tin e. Wh at is believed to be th e basis o th e th erap eu tic action o m em an tin e on n eu ron s in th e b rain ?

associated with th e disp lay o n egative sym p tom s in sch izop h ren ia is th e

(A) To in h ibit th e action o (B) (C) (D) (E)

acetylch olin esterase To block th e in lu x o calciu m To in h ibit th e action o acetylch olin e To in crease th e in lu x o glu tam ate To acilitate th e in lu x o calciu m

(A) (B) (C) (D) (E)

m esocortical tract m esolim b ic tract tu beroin u n dibu lar tract ceru locortical tract rap h e cortical tract

An swers an d Exp lan ation s

Typical Board Question The answer is A. Dam age to th e righ t p arietal lob e can resu lt in im p aired visu al–sp atial p rocessin g. Th is can lead to p rob lem s copyin g sim p le drawin gs an d n eglect o th e le t side as seen in th is p atien t.

1. The answer is F. O th e listed brain areas, d ep ression is m ost likely to b e associated with d am age to th e le t ron tal lobe.

2. The answer is D. A 24-h ou r u rin e stu dy is m ost likely to reveal elevated levels o VMA, a m etab olite o n orep in ep h rin e. An xiety, ab dom in al cram p s an d d iarrh ea, an d skin lu sh in g are sym p tom s o p h eoch rom ocytom a, a n orep in ep h rin e-secretin g adren al tu m or. Th is p ictu re is n ot seen with elevated levels o oth er n eu rotran sm itter m etabolites.

3. The answer is C. Sin ce th e p lacebo respon se is based in part on activation o the en dogen ou s op ioid system , it will be blocked by n aloxon e, an d this p atien t’s pain will be u n ch an ged. Th is exp erim en t will n ot n ecessarily a ect her respon se to opioids in the uture.

4. The answer is D. Dom in an ce or lan gu age in both righ t-h an ded an d le t-h an ded p eop le is u su ally in th e le t h em isp h ere o th e brain . Percep tion , m u sical ability, artistic ability, an d sp atial relation s p rim arily are u n ction s o th e righ t sid e o th e brain .

5. The answer is D. Th e corp u s callosu m an d th e h ip p ocam p al, h aben u lar, an d an terior com m issu res con n ect th e two h em isp h eres o th e b rain . Th e basal gan glia, reticu lar system , an d am ygd ala do n ot h ave th is u n ction .

6. The answer is D. Sedation , in creased appetite, an d weight gain are side e ects o treatm en t with certain an tipsychotic agen ts. The m echan ism m ost closely associated with these side e ects is blockade o histam in e receptors sin ce these an tipsychotics are n ot speci ic or dopam in e blockade. Blockade o dopam in e receptors by these antipsychotic m edications is associated with side e ects such as parkinsonism -like sym ptom s an d elevated prolactin levels.

7. The answer is E. Th is 3-year-old girl is sh owin g sign s o Rett’s disorder th at is lin ked to th e X ch rom osom e. Rett’s d isord er is ch aracterized by loss o social skills a ter a p eriod o typ ical un ction in g as well as h an d-wrin gin g an d breath in g abn orm alities (see also Ch ap ter 15).

8. The answer is F. Wh ile acetylch olin e (Ach ) is th e m ajor n eu rotran sm itter im p licated in Alzh eim er’s disease, abn orm alities in glu tam ate are seen in both Alzh eim er’s disease an d sch izop h ren ia.

9. The answer is A. Blockade o seroton in reu p take by p resyn ap tic n eu ron s is th e p rim ary action o th e an tidep ressan t lu oxetin e.

10. The answer is A. Seroton in is m etabolized to 5-HIAA. 11. The answer is E. Th e p atien t is sh owin g evid en ce o th e Klü ver-Bu cy syn drom e, wh ich in clu d es h yp ersexu ality an d docility an d is associated with dam age to th e am ygdala.

12. The answer is D. Sleep –arou sal m ech an ism s are a ected by dam age to th e reticu lar system .

13. The answer is D. Alth ou gh n eu roim agin g can n ot be u sed to diagn ose p sych iatric disorders, brain s o p atien ts with sch izop h ren ia su ch as th is wom an are likely to sh ow d ecreased volu m e o lim b ic stru ctu res su ch as th e h ip p ocam p u s; in creased size o cerebral ven tricles du e, in p art, to b rain sh rin kage; an d decreased glu cose u tilization in th e ron tal cortex.

46

Chapter 4

Genetics, Anatomy, and Biochemistry of Behavior

47

14. The answer is B. Th is 80-year-old em ale p atien t is sh owin g sign s o Parkin son’s disease (e.g., a restin g trem or, little acial exp ression , an d p roblem s in itiatin g m ovem en t). Th is disord er is associated with ab n orm alities o th e b asal gan glia.

15. The answers is C. 16. The answer is E. This patien t is sh owin g eviden ce o Alzh eim er’s disease. O th e listed brain areas, th e m ajor on e im p licated in Alzheim er’s disease is th e h ip p ocam p u s. Am yloid p laqu es are seen on brain biop sy o Alzheim er’s disease p atien ts.

17. The answer is D. Assau ltive, im p u lsive, aggressive beh avior like th at seen in th is 28-year-old m ale p atien t is associated with decreased levels o seroton in in th e brain . Levels o 5-HIAA (5-h yd roxyin d oleacetic acid), th e m ajor m etabolite o seroton in , h ave been sh own to b e decreased in th e body lu ids o violen t, aggressive, im p u lsive in dividu als as well as dep ressed in dividu als. MHPG (3-m eth oxy-4h ydroxyp h en ylglycol), a m etab olite o n orep in ep h rin e, is decreased in severe dep ression , wh ile h om ovan illic acid (HVA), a m etabolite o d op am in e, is d ecreased in Parkin son’s disease an d d ep ression .

18. The answer is C. Th e e ectiven ess o clon idin e in treatin g with drawal sym p tom s associated with th e u se o op ioids an d sedatives is believed to be du e to its action on alp h a 2-ad ren ergic recep tors, or exam p le, red u cin g th e irin g rate o n orad ren ergic n eu ron s, m ost o wh ich are located in th e locu s ceru leu s.

19. The answer is B. g-Am in ob u tyric acid (GABA) is an in h ibitory am in o acid n eu rotran sm itter in th e CNS. Th u s, th e activity o GABA in th e brain o th is an xiou s p atien t is likely to be decreased. Decreased seroton in an d in creased dop am in e are also in volved in an xiety (Table 4.4).

20. The answer is C. Beh avioral ch an ges su ch as decreased im p u lse con trol, p oor social beh avior, an d lack o ch aracteristic m odesty in d icate th at th e area o th e b rain m ost likely to h ave b een in ju red in th is p atien t is th e orbito ron tal cortex. Lesion s o th is brain area resu lt in d isin h ib ition , in ap p rop riate beh avior, an d p oor ju d gm en t. In con trast, lesion s o th e dorsolateral con vexity o th e ron tal lobe resu lt in decreased execu tive u n ction in g (e.g., m otivation , con cen tration , an d atten tion ). Th e h yp oth alam u s is associated with h om eostatic m ech an ism s an d th e reticu lar system with con sciou sn ess an d sleep. Dam age to th e am ygdala resu lts in decreased, n ot in creased, aggression . Th e n u cleu s basalis o Meyn ert is a site o Ach p rodu ction ; its dam age cou ld resu lt in d e icits in in tellectu al u n ction in g.

21. The answer is E. In creased body lu id level o hom ovan illic acid (HVA), a m ajor m etabolite o dopam in e, is seen in sch izoph ren ia. Decreased HVA is seen in Parkin son’s disease, depression , an d in m edicated schizophren ic patien ts. In creased van illylm an delic acid (VMA), a m etabolite o n orep in ep h rin e, is seen in p heoch rom ocytom a. Decreased body luid level o 5-HIAA, a m etabolite o seroton in , is seen in depression an d in bulim ia (Table 4.5).

22. The answer is A. Rem em berin g th at sch ool closes early be ore Th an ksgivin g Day every year is an exam p le o sem an tic m em ory. Sem an tic m em ory is a typ e o declarative m em ory th at in volves rem em berin g gen eral kn owledge abou t th e world. Ep isodic m em ory in volves rem em berin g p erson ally exp erien ced even ts, p rocedu ral m em ory in volves rem em berin g th in gs on e does au tom atically, an d workin g m em ory in volves rem em berin g recen t in orm ation .

23. The answer is B. Decreased availability o acetylch olin e by blockade o m u scarin ic acetylch olin e recep tors (i.e., an tich olin ergic activity) in th e CNS is associated with m em ory p rob lem s. Blockade o ad ren ergic, d op am in ergic, h istam in ergic, an d seroton ergic recep tors are less likely to b e associated with m em ory p rob lem s.

24. The answer is B. Ch rom osom e 16 an d ch rom osom e 9 are b oth associated with tu berou s sclerosis. Seizu res, cogn itive de ects, au tistic beh avior, an d oreh ead p laqu es in th is 6-year-old ch ild are seen in th is disorder.

48

BRS Behavioral Science

25. The answer is B. Th e th erap eu tic action o m em an tin e in Alzh eim er’s d isease is b elieved to be to d ecrease th e in lu x o glu tam ate, u ltim ately b lockin g th e in lu x o calciu m , wh ich can lead to n erve cell degen eration an d d eath . In con trast to a grou p o dru gs also u sed to treat Alzh eim er’s, th at is, th e acetylch olin esterase in h ib itors, m em an tin e d oes n ot directly a ect acetylch olin e.

26. The answer is E. Th e am ygdala is an im p ortan t b rain area or th e evalu ation o sen sory stim u li with em otion al sign i ican ce. Th u s, th e brain area m ost likely to be activated by th ese p h otos is th e am ygdala.

27. The answer is A. Dop am in e h yp oactivity in th e m esocortical tract is associated with th e n egative sym p tom s o sch izop h ren ia (an d see Ch ap ter 11). Dop am in e h yp eractivity in th e m esolim b ic tract is associated with th e p ositive sym p tom s o sch izop h ren ia. Dop am in e acts on th e tu beroin u n d ibu lar tract to in h ibit th e secretion o p rolactin rom th e an terior p itu itary. Th e cerulocortical tract is associated with th e action o n orep in ep h rin e, wh ile th e rap h e cortical tract is associated with th e action o seroton in .

c ha pte r

5

Biological Assessm en t o Patien ts with Psych iatric Sym p tom s

Typical Board Question A college-edu cated 72-year-old em ale p atien t h as scored 15 on th e Folstein Min i–Men tal State Exam in ation . From th is score, th e p h ysician can con clu de th at th is p atien t p robably

(A) (B) (C) (D) (E)

is sh owin g typ ical b eh avior can n ot calcu late sim p le su m s is cogn itively im p aired sh ou ld be p laced in an assisted livin g acility h as lower th an n orm al in telligen ce

(See “An sw ers an d Explan ation s” at th e en d of th e ch apter.)

I. OVERVIEW Biological alteration s an d ab n orm alities can u n derlie p sych iatric sym p tom s an d in lu en ce th eir occu rren ce. A variety o laboratory stu d ies are u sed clin ically to iden ti y su ch alteration s an d abn orm alities in p atien ts.

II. MEASUREMENT OF BIOGENIC AMINES AND PSYCHOTROPIC DRUGS A. Altered levels o b iogen ic am in es an d th eir m etabolites occu r in som e p sych iatric con dition s (see Tab les 4.2 an d 4.3).

B. Plasm a levels o som e an tip sych otic an d an tidep ressan t agen ts are m easu red to evalu ate patient compliance or to determ in e wh eth er therapeutic blood levels o th e agen t h ave been reach ed.

C. Laboratory tests also are used to monitor patients for complications of pharmacotherapy. 1. Patien ts takin g certain m ood stabilizers, or exam p le, carbam azep in e (Tegretol), or an tip sych otics, or exam p le, clozap in e (Clozaril), m u st be observed or blood abn orm alities su ch as agranulocytosis (very low, e.g., 10 min

REM latency

About 90 min

About 45 min

About 90 min

Sleep efficiency

About 100%