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Behavioral Science

Semester Review

This packet of information has been prepared by Daniele Bonafiglia, as a

contribution to the student body at Ross University.
August, 2001

DSM-IV Classifications

Axis I: Clinical Disorders and other conditions that would be the focus of clinical attention
Disorders first diagnosed in infancy/childhood/adolescence (not M.R)
Cognitive Disorders
Mental Disorders due to general medical condition
Substance Related Disorders
Schizophrenia, Psychotic Disorders
Mood Disorders
Anxiety Disorders
Somatoform Disorders
Factitious Disorders
Dissociative Disorders
Sexual & Gender Identity Disorders
Eating Disorders
Sleeping Disorders
Impulse Control Disorders
Adjustment Disorders

Axis II: Personality Disorders and Mental Retardation

Paranoid Personality Disorder
Schizoid Personality Disorder
Schizotypal Personality Disorder
Antisocial Personality Disorder
Borderline Personality Disorder
Histrionic Personality Disorder
Narcissistic Personality Disorder
Avoidant Personality Disorder
Dependent Personality Disorder
Obsessive-Compulsive Personality Disorder
Personality Disorder N.O.S
Mental Retardation

Axis III: Physical disorder or general medical condition present in addition to a mental

Axis IV: Psychosocial and environmental problems that contribute to the development or
exacerbation of the disorder

**Important in the diagnosis of all disorders -> There is significant

distress or impairment of social, occupational or other functioning**

Anatomy and Biochemistry of Behavior
Right side of brain (nondominant)spatial relations, musical ability, facial recognition, social
cue perception
Left side of brain (dominant)  language function

Location of Lesion Consequences

Frontal Lobe Shallow affect, depression, reduced motivation
Attention/memory problems, inappropriate behavior,
dominant lesions=poor expressive speech (Broca’s aphasia)
Temporal Lobe Impaired memory, psychomotor seizures, dominant
lesions=poor verbal comprehension (Wernicke’s aphasia)
Hippocampus Poor new learning, implicated in Alzheimer’s
Amygdala Docility and increased sexual behavior (Kluver-Bucy)
Parietal Lobes Problems w/ intellectual processing of sensory and verbal
Occipital Lobes Visual hallucinations and illusions, blindness, disturbances
of spatial orientation
Thalamus Increased pain perception, impaired memory and arousal
Basal ganglia Disorders of mvmt, thought, affect, cognition, Parkinson’s,
Cerebellum Atrophy may be seen in schizophrenia, bipolar disorder,
epilepsy, autism
Reticular system Sleep-arousal mechanisms affected
Limbic system Emotion, memory, mediation btwn cortex and lower
centers affected
Hypothalamus Problems w/ eating, sexual activity, body temp regulation
and sleep-wake cycle

Psychiatric Condition Neurotransmitter

Schizophrenia Dopamine
Depression Norepinephrine, serotonin, dopamine
Anxiety GABA, norepinephrine, serotonin
Alzeheimer’s Disease Acetylcholine

Dopamine=a catecholamine
Blockade of dopamine=elevated prolactin levels
HVA = metabolite of dopamine
Norepinephrine=role in sleep-wake cycle, arousal, anxiety, learning, memory, pain
MHPG=metabolite of norepinephrine
VMA= metabolite of norepinephrine
Serotonin=anxiety and violence, affective disorders, sleep
Increased serotonin=decreased sexual activity
5-HIAA=metabolite of serotonin
GABA=presynaptic inhibition of CNS
Decreased GABA activityepilepsy, anxiety
Loss of GABAHuntington’s, Parkinson’s

Neuropeptide Psychopathology
Cholecystokinin Schizophrenia, eating / movement disorders
Neurotensin Schizophrenia
Somatostatin Huntington’s, Alzeheimer’s, Mood disorders
Substance P Pain, Huntington’s Mood disorders
Vasopressin Mood disorders
Vasoactive Intestinal Peptide Dementia, Mood disorders

Life Cycle
Pseudocyesis = false pregnancy
50% of unmarried moms are teenagers
Ave. age of 1st intercourse=16yrs
Predisposing factors of teenage pregnancy=depression, low academic achievement/goals, poor
future planning, divorced parent

Low SEShigh infant mortality
Mortality Rate: blacks highest, Native Americans, Americans
Prematurity=gestation<34 weeks or birth weight<2500g
Mother-Child Bonding adversely affected by low birth weight, child’s illness, separation from
mom after delivery, problems in mom-dad relationship
Post partum blues (baby blues) develops in 1/3-1/2 of women, a result of changes in hormone
levels, stress of childbirth, awareness of responsibility, disappointment over child’s appearance,
5-10% of women suffer from Major Depression after childbirth, .1-.2% of which will develop
postpartum psychosis
Factors related to long-lasting postpartum reactions=lack of child care experience, lack of social

Theories of Child Development

Oral Stage 0-1 years: mouth is major site of gratification
Anal Stage 1-3 years: control over toilet training
Phallic Stage 3-5 years: focus of pleasure is genitals, “oedipal conflict”
Latency Stage 6-11 years: no psychosexual issues of importance
Genital Stage 11-20 years: intensification of drives, establish relationship

Sensorimotor 0-2 years: mastery of environment comes from assimilation
(understanding new things) and accommodation (altering behavior b/c of new
things), “object permanence”-maintain internal representations 12-24mo
Preoperational 2-7 years: child begins to think in symbolic terms
Concrete Operational 7-11 years: capacity for logical thought

Formal Operations 11-20 years: abstract reasoning

Trust vs. Mistrust 0-1 years: to establish trust, child’s basic needs must
be met consistently
Autonomy vs. Self-doubt 1-3 years: child resolves internal desires for
independence with parental control, “autonomy”
Initiative vs. Guilt 3-5 years: child begins to take risks, w/ fear of
punishment and sense of guilt
Industry vs. Inferiority 6-11 years: acquires sense of competence or
incompetence in interactions w/ world
Identity vs. Diffusion 11-20 years: develop sense of independent self
Intimacy vs. Isolation 20-40 years: inability to have intimate relationship
will lead to emotional isolation
Generativity vs. Stagnation 40-65 years: maintenance of sense of
productivity or develops sense of emptiness and stagnation
Ego Integrity vs. Despair 65+: either a satisfaction and pride in one’s
accomplishments or sense of worthlessness

Infancy: Birth – 15 months

Infant reflexes=palmar grasp, babinski’s, rooting
Socialization begins at birth, social smile at 5-8wks
Stranger anxiety at 7-9 months
Toddler: 15 months - 2.5 years
Major theme=separation from mother
Separation anxiety peaks at 18 months
Core gender identity established btwn 18-30 mos
Parallel play
Preschool: 2.5 – 6 years
Half of adult height is reached
Rapid increase in vocabulary
Nightmares, transient phobias common
“Band-Aid” phase
Interest in physical sex differences, play “doctor”
Conscience (superego) begins to develop
Role-play, Cooperative play, Imaginary companionsdecrease loneliness/anxiety
School Age (Latency): 7 – 11 years
Performs complex motor tasks/activities
Conscience is completely developed
Success in school is important
Identifies w/ teachers, peers, who are viewed as more important than family
Preference for play w/ same sex peers
Adolescence: 11 – 20 years

Formation of the personality
Strong sexual impulses, hormonal changes
Attempts at independence
Development of morals/ethics
Identity crisis, if incorrectly handledidentity diffusion, role confusion
Early Adulthood: 20 – 40 years
Social role defined, Independent self develops
Age 30=period of reappraisal
Main responsibility=develop intimate relationship
Middle Adulthood: 40 – 65 years
Middle adulthood=positions of power/authority
“Mid-Life Crisis”inability to change life pattern that individual finds unendurable,
panic about what hasn’t been accomplished in life
Predisposing Factors: problems w/parents, low self-esteem, anxiety, impulsivity,
weak/absent same-sex parent
Late Adulthood: 65 years – death
80% of people in US reach age 60+
Life expectancy: white female=80, w male=73, black female=74, b male=65
Depression is the most common psychiatric illness in elderly (15%)
Associated factors of dep.=loss of loved ones, loss of prestige, loss of health, TX: ECT
Longevityfamily history, physically active work, 6-9 hrs sleep/night, advanced
education, suburban living, marriage, strong social supports, calm personality,
occupational activity
Stages of Death: 1.Denial 2.Anger 3.Bargaining 4.Depression 5.Acceptance
Normal grief=1-2 years

Childhood Disorders
Most childhood problems have a familial pattern
More childhood psychological problems occur in males

Mental Retardation, 1% of population, onset prior to 18yrs, more common in males

• Significant subaverage intellectual functioning: an IQ of approx. 70 or below
• Concurrent deficits or impairments in present adaptive functioning in at least 2 of the
following (communication, self-care, home living, social/interpersonal skills, use of
community resources, self-direction, academic skills, work, leisure, health and safety)
Mild: 50/55 - 70 IQ Level (85% of cases, trainable, at 18yrs=6th gr. level)
Moderate: 35/40 – 50/55 IQ Level (10% of cases, trainable, can acquire work skills and
live in supervised community)
Severe: 20/25 – 35/40 IQ Level (3%, poor speech, trained to talk)
Profound: IQ Level below 20/25 (least common, neuro-deficit, institutionalized)

Predisposing factors for Mental Retardation: heredity(5%), embryonic(30%), perinatal (10%),

infant medical conditions(5%) environmental(15-20% very significant)
Mental Retardation w/ Genetic Components: Down’s Syndrome, Fragile X, Klinefelter’s,
Turner’s, Cri du chat, Tay Sachs

Most common metabolic chromosomal abnormalities: Down’s, Fragile X, Phenylketonuria

Expressive Language Disorder, 3-5% prevalence

• Scores obtained from a battery of standardized measure of
expressive language are substantially below those of nonverbal intellectual capacity
and receptive language development. This disturbance may be manifest by symptoms
that include limited vocabulary, making errors in tense, and/or difficulty recalling
words or producing sentences

ExpressiveFrontal Lobe, Broca’s aphasia

Onset by age 3
Affects non verbal, “body language” in addition to verbal

Mixed-Receptive Expressive Language Disorder, 3% prevalence

• Scores obtained from a battery of standardized measure of both
receptive and expressive language development are substantially below those of
nonverbal intellectual capacity. Symptoms include those for expressive language
disorder as well as difficulty understanding words, sentences, or specific types of

Receptive Temporal Lobe, Wernicke’s aphasia,

Onset 3-9 years
Language disorder w/ seizures=Lander Kleiner syndrome

Phonological Disorder, 2-5% prevalence, more common in males

Failure to use developmentally expected speech sounds that are age- and dialect

Stuttering, 1% prevalence
• Disturbance in normal fluency and time patterning of speech with
one or more of the following: sound and syllable repetitions, sound prolongations,
interjections, broken words, audible or silent blocking, circumlocutions (word
substitutions), words produced with and excess of physical tension, monosyllabic
whole-word repetitions

Increased by anxiety, often perfectionist families increase anxiety

Onset 2-7 years, calms with age
May have motor movements of head

Pervasive Developmental Disorders- severe, pervasive impairment in developmental areas,

such as social interaction and communication, or stereotyped behavior, interests and
activities. Onset is before age 3. Associated w/ mental retardation. Examples include the
following Autism, Rett’s Disorder, Asperger’s Disorder and Childhood Disintegrative

Autistic Disorder, 5 children per 10,000 births (.005%), more common in boys

• Impairment in social interaction as manifested by 2 of the
 Marked impairment in the use of multiple nonverbal behaviors
 Failure to develop age-appropriate peer relationships
 Lack of spontaneous seeking to share enjoyment w/ others
• Impairments in communication as manifested by at least 1 of the
 Delay in, or lack of, development of spoken language
 In those w/ speech, impairment in ability to initiate or sustain
 Stereotyped, repetitive use of language or idiosyncratic language
 Lack of varied, age-appropriate, spontaneous make-believe or
parallel play
• Restricted, repetitive and stereotyped patterns of behavior,
interests, and activities as
manifested by at least 1 of the following:
 Stereotyped, repetitive patterns of interest that is abnormal in
intensity and/or focus
 Inflexible adherence to specific, nonfunctional routines or rituals
 Stereotyped, repetitive motor mannerisms
 Preoccupation w/ parts of objects
• Delays, abnormal functioning in at least 1 of the following
areas(w/onset prior to 3yrs):
 Social interaction
 Language as used in social communication
 Symbolic or imaginative play

Onset is before age 3

Neurologic abnormalities, perinatal compromise, increased serum serotonin, genetic component
May result from encephalitis, rubella
Course is variable, 1/3 become partially independent adults

Rett’s Disorder
 Apparently normal prenatal and perinatal development
 Apparently normal psychomotor development through the first 5
mo. after birth
• Onset of the following after the period of normal development:
 Deceleration of head growth between ages 5 and 48 months
• Loss of previously acquired purposeful hand skills between 5-30
months, w/ development of stereotyped hand movements
 Loss of social engagement early in course
 Appearance of poorly coordinated gait or trunk movements
 Severely impaired expressive and receptive language development
 Severe psychomotor retardation

Asperger’s Disorder
• Impairment in social interaction as manifested by AT LEAST 2 OF
• Impairment in the use of multiple nonverbal behaviors (eye-eye
gaze, facial expression, body posture, social gestures)
• Failure to develop age appropriate peer relations
• Lack of spontaneous seeking to share joy, interests, achievements
w/ others
• Lack of social, emotional reciprocity
• Restricted, repetitive, stereotyped patterns of behavior, interests,
and activities, as
manifested by AT LEAST 1 OF THE FOLLOWING:
 Encompassing preoccupation with 1 or more stereotyped and restricted
patterns of interest that is abnormal in intensity of focus
 Apparently inflexible adherence to specific, nonfunctional routines/rituals
 Stereotyped and repetitive motor mannerisms
 Persistent preoccupation with parts of objects

Childhood Disintegrative Disorder

• Normal development for at least the first 2 years after birth
• Clinically significant loss of previously acquired skills (before age
10) in AT LEAST 2
 Expressive or receptive language
 Social skills or adaptive behavior
 Bowel or bladder control
 Play
 Motor skills
• Abnormalities of functioning in AT LEAST 2 OF THE FOLLOWING AREAS:
• Impairment in social interaction
• Impairment in communication
• Restricted, repetitive and stereotyped behavior, interests, and
activities including motor stereotypes and mannerisms

Attention Deficit / Hyperactivity Disorder (ADHD), 3-5% of children btwn 5-12 yrs
• Symptoms must have persisted FOR AT LEAST 6 MONTHS
• Either 6 OR MORE of the following symptoms of INATTENTION:
 Fails to give close attention to details or makes careless mistakes
 Has difficulty sustaining attention in task or play
 Does not seem to listen when spoken to directly
 Does not follow through on instructions, fails to finish work/duties
 Has difficulty organizing tasks/activities
 Avoids, dislikes, reluctant to engage in tasks requiring sustained mental

 Loses things needed for tasks/activities
 Easily distracted by extraneous stimuli
 Forgetful in daily activities
• Fidgets w/ hands or feet or squirms in seat
• Leaves seat in classroom or other situations when sitting is expected
• Runs about or climbs excessively in situations when it’s inappropriate
• Difficulty playing or engaging in leisure activities quietly
• Often “on the go” or often acts as if “driven by a motor”
• Talks excessively
• Blurts out answers before questions have been completed
• Difficulty waiting turn
• Interrupts or intrudes on others
• Some hyperactive-impulsive or inattentive symptoms were present
before 7yrs
• Some symptoms present in 2 or more settings (school, work,

5X more common in boys

Biochemical disturbance thought to be at reticular formation
Genetic component
TX: Work with family, Amphetamines (methylphenidate: Ritalin, dextraphenidate), CNS
stimulants, Well Butrin

Oppositional-Defiant Disorder
 Pattern of negativistic, hostile and other defiant behavior lasting AT LEAST 6 MONTHS
 During which 4 OR MORE OF THE FOLLOWING:
 Loses temper
 Argues with adults
 Actively defies or refuses to comply w/ adult requests/rules
 Deliberately annoys people
 Blames others for his/her mistakes/misbehavior
 Touchy, easily annoyed by others
 Angry and resentful
 Spiteful or vindictive

TX: family and behavioral therapy

Conduct Disorder
 Repetitive, persistent pattern of behavior in which either the basic rights of others
or major age-appropriate societal norms are violated. Manifested by 3 OR MORE OF
THE FOLLOWING, present in the PAST 6 MONTHS:
 Aggression to people and animals
• Bullies, threatens, intimidates others
• Initiates physical fights

• Used a weapon that can cause harm to others
• Been physically cruel to people or animals
• Stolen while confronting victim
• Forced someone into sexual activity
Destruction of property
 Deliberately engaged in fire setting w/ intent of damage
 Deliberately destroyed others’ property
Deceitfulness or theft
• Broken into another’s house, bldg, car
• Lies to obtain goods/favors or to avoid obligation
• Stolen items of nontrivial value w/out confronting victim
Serious violation of rules
 Stays out at night despite parental rules (beginning before
 Has run away from home overnight at least 2X
 Truant from school (beginning before 13yrs)

Biologic Factors: low serotonin and somatostatin levels

TX: Rule out depression, family therapy (parenting skills), behavior therapy (BEST), Propanol,
Clonidine, Tegretol, residential care

Eating of nonnutritive substances for a period of at least 1 MONTH

Regurgitation and rechewing of food for a period of at least 1 MONTH

Tourette’s Disorder, 3X more common in boys, .005% prevalence

• Both multiple motor and 1 or more vocal tics have been present
• Tics occur many times a day, nearly every day for MORE THAN 1 YEAR
• Onset before 18yrs

“Corporalalia”-vocal tics w/ swearing

Dysfunctional regulation of dopamine
Most common TX: haloperidol, chlonodine, beta blockers

Chronic Motor / Vocal Tic Disorder

• Single or multiple motor or vocal tics, but not both
• Tics occur many times a day, nearly every day for MORE THAN 1 YEAR
• Onset before 18yrs

Encopresis, 1% of 5 year olds

• Repeated passage of feces into inappropriate places involuntarily or intentional
• At least 4 yrs old

Enuresis, 7% male prevalence, 3% female
• Repeated voiding of urine into bed or clothes involuntarily or intentional
• At least 5 yrs old

Separation Anxiety Disorder, 4% prevalence, male=female

• Developmentally inappropriate and excessive anxiety concerning separation from home
or those to whom individual is attached. 3 OR MORE OF THE FOLLOWING:
 Recurrent excessive distress when separated from home or
attachment figure
 Worry about losing, or about harm befalling attachment figure
 Worry that an event will lead to separation from attachment figure
 Refusal to go to school or elsewhere
 Fearful or reluctant to be w/out adults
 Refusal to go to sleep w/out being near attachment figure
 Refusal to sleep away from home
 Complaints of physical symptoms when anticipating separation
• Duration of disturbance is AT LEAST 4 WEEKS
• Onset before 18yrs

Associated features=close-knit family, anxious parent

TX: Easy kids to work with, family and individual therapy

Depression (Dysthymia for 1 year): 10% prevalence

TX: cannot use tricyclics before age 12

Childhood onset is rare, 2 per 100,000
Associated w/ low IQ, symptom of autism
TX: Social skills training, Clozapine (best)

Sleep Disorders
Normal Sleep:
6-9 hours a day, restorative
Stage 1-4 NonREM sleep: peacefulness, slowed pulse & respiration, decreased blood
pressure, episodic body mvmts
Stage 3-4 (delta sleep) Deepest, most relaxed, bed-wetting, night terrors
REM Sleep: increased pulse, inc. respiration, inc. blood pressure, inc. brain oxygen use,
penile/clitoral erection, muscle paralysis, DREAMS
REM Latency= 90 minutes after falling asleep, every 90 minutes thereafter, last 1/3 of
Newborns 50% REM, Adults 25% REM
Sleep deprivationego disorganization, hallucinations, delusions
REM deprivation lead to irritability and lethargy

Dysomnias: 33% lifetime prevalence
Primary Insomnia: 30% prevalence, MOST COMMON DYSOMNIA
• Difficulty initiating or maintaining sleep FOR AT LEAST 1 MONTH

TX: underlying condition, meds (dopamine blockers increase sleep), sleep


Primary Hypersomnia, (Less Common)

• Excessive sleepiness FOR AT LEAST 1 MONTH evidence by prolonged
sleep episodes or daily daytime sleep episodes

TX: Increase dopamine increase wakefulness

Narcolepsy, 1% prevalence (Most Dangerous)

• Irresistible attacks of refreshing sleep that occur daily over AT LEAST 3
• Presence of cataplexy and/or hypnopompic or hypnagogic hallucinations or
• Paralysis

50% of narcolepsy patients collapse due to loss of muscle tone, “cataplexy”

TX: Stimulants, Increase dopamine increase wakefulness

Sleep Apnea
Central airflow and respiratory efforts stop

Sleep Terror Disorder, 1-6% of children, most common in boys
• Recurrent episodes of abrupt awakening from sleep with a panicky scream,
during first 3rd of sleep episodes
• Intense fear, Autonomic arousal
• Unresponsive to comfort

TX: Benzodiazapines

Nightmare Disorder
• Repeated awakening from the major sleep period or naps w/ detailed recall of
frightening dreams

TX: Agents that suppress REM (tricyclics, antidepressants, benzodiazepines)

Sleepwalking Disorder
Repeated rising from bed
Occurs during NonRem Stages 3 and 4

Eating Disorders
More common in women than men

Anorexia Nervosa, prevalence 5%, .5-1% of adolescent girls

• Refusal to maintain body weight at or above normal weight for age and height
(85% of expected body weight)
• Intense fear of gaining weight or becoming fat
• Disturbance in experience of body weight/shape
• Amenorrhea
Anorexia Nervosa Restricting Type: Has not engaged in binge eating or purging behavior 50%
Anorexia Nervosa Binge Eating/Purging Type: Regularly engaging in binge eating and
purging behavior 50%

Age of onset: mid-teens-mid-twenties (late adolescence)

Physical symptoms: hypothermia, hypotension, bradycardia, lanugo hair, osteoporosis, seizures,
cold intolerance, poor sexual adjustment
Preoccupied with food/cooking, obsessive compulsive behavior
50% Co-morbidity w/ Depression, Risk of suicide high
Decreased norepinephrine
Developing autonomy and selfhood avoided by weight loss, “I don’t want to grow up and be
Resistant to TX
TX: Weight gain (1st priority), Family therapy, Psychoactives (amitriptyline, cyproheptadine)

Bulimia Nervosa, 1-3% prevalence

• Recurrent episodes of binge eating -> eating lots of food in a short amount of time
while feeling out of control
• Recurrent behavior to prevent weight gain (vomiting, laxatives, enemas, etc)
• Behaviors occur AT LEAST 2X A WEEK FOR 3 MONTHS
Bulimia Nervosa Purging Type: regularly engaging in self-induced vomiting, laxatives,
Bulimia Nervosa Nonpurging Type: fasting or excessive exercise rather than vomiting, etc.

Age of onset: Adolescence

Usually at or near normal body weight
Not about weight loss, but preventing weight gain
Binge=Loss of controlguilt, depression
Amenorrhea is rare
Sexually active
Bulimia is about other “I want to be not fat so people will love me” versus Anorexia about self,
“I feel fat and want to be thin for me”
Better prognosis, will seek treatment
TX: Psychotherapy, behavior therapy, antidepressants, MAOs, fluoxetine

Obesity (not a DMS-IV diagnosis)

Excessive accumulation of fat in the body (20% over ideal body weight)
50% of US adults are obese
More common in low SES, women

Binge Eating
• Episodes of binge eating that occur AT LEAST 2X A WEEK FOR 6 MONTHS
• No inappropriate compensatory behavior (vomiting, laxatives, enemas, etc)

Sexual Dysfunctions
Normal Sexual Response Cycle:
Desire-appetitive phase, strictly psychological: fantasies and desires
Excitement-psychological and physiological stimulation, subjective sense of pleasure, penile
tumescence/vaginal lubrication
Orgasm-peaking of sexual pleasure, release of sexual tension, rhythmic contraction of
muscles/pelvic organs
Resolution-body returns to resting state

“Primary Dysfunction”=always been present

“Secondary Dysfunction”=occurs after an interval when functioning was normal

Treatment for most Sexual Dysfunctions: Dual Sex Therapy (male & female therapists),
hypnosis, behavior therapy (systematic desensitization, assertiveness training), group therapy,
biofeedback, analytically oriented (psychoanalytic) sex therapy-**most effective**

**Androgenic drugs increase sex drive in women**

Hypoactive Sexual Desire Disorder

• Persistent, recurrent deficiency or lack of sexual fantasies and desire for sexual

Sexual Aversion Disorder

• Persistent, recurrent extreme aversion to/avoidance of all genital sexual contact w/

Female Sexual Arousal Disorder

• Persistent, recurrent inability to attain or maintain until completion of the sexual
activity, an adequate lubrication-swelling response to sexual excitement

Male Erectile Disorder

• Persistent, recurrent inability to attain or maintain until completion of the sexual
activity, an adequate erection

Female Orgasmic Disorder

• Persistent, recurrent delay in or absence of orgasm following a normal sexual
excitement phase

• Women exhibit variability in type/intensity of stimulation that triggers orgasm.
Diagnosis must take this into account.

Male Orgasmic Disorder

• Persistent, recurrent delay in or absence of orgasm following a normal
sexual excitement phase during sexual activity

Premature Ejaculation
• Persistent, recurrent ejaculation w/ minimal sexual stimulation before, on,
or shortly after penetration, and before intending to

Factors: Stress, negative cultural conditioning, general medical factors

More common in college educated population
TX: sex-therapy, squeeze technique raises penile excitement threshold, stop-start technique

• Recurrent, persistent genital pain associated w/ sexual intercourse in male
or female

• Recurrent, persistent involuntary spasm of the musculature of outer 1/3 of
vagina that interferes w/ sexual intercourse

TX: methods to dilate vaginal opening

Paraphilia- Unusual fantasies or sexual urges/behaviors that are recurrent and sexually
arousing. Must occur for AT LEAST 6 MONTHS. The following are examples of:

• Recurrent, intense sexually arousing fantasies, sexual urges, or behaviors involving the
exposure of one’s genitals to an unsuspecting stranger

• Recurrent, intense sexually arousing fantasies, sexual urges, or behaviors involving the
use of nonliving objects

• Recurrent, intense sexually arousing fantasies, sexual urges, or behaviors involving
touching and rubbing against a nonconsenting person

• Recurrent, intense sexually arousing fantasies, sexual urges, or behaviors involving
sexual activity with a prepubescent child or children (generally age 13 or younger)

Sexual Masochism
• Recurrent, intense sexually arousing fantasies, sexual urges, or behaviors involving the
act (real, not stimulated) of being humiliated, beaten, bound, or otherwise made to suffer

Sexual Sadism
• Recurrent, intense sexually arousing fantasies, sexual urges, or behaviors involving acts
(real, not stimulated) in which the psychological or physical suffering (including
humiliation) of the victim is sexually exciting to the person

• Recurrent, intense sexually arousing fantasies, sexual urges, or behaviors involving the
act of observing an unsuspecting person who is naked, in the process of disrobing, or
engaging in sexual activity

Transvestic Fetishism
• In a heterosexual male, recurrent, intense sexually arousing fantasies, sexual urges, or
behaviors involving cross-dressing
with gender dysphoria if the person has persistent discomfort w/ gender role or identity

Illness and Sexuality

Myocardial Infarctionerectile dysfunction, decreased libido
Diabeteserectile dysfunction in 25-50% of diabetic men b/c of vascular changes and
diabetic neuropathy
Spinal cord injurybetter sexual prognosis if incomplete, lower motor neuron lesion

Drugs and Sex:

Alcohol decreases erection and vaginal lubrication
Marijuana psychologically enhances enjoyment, chronic use=low testosterone levels,
pituitary gonadotropin
Heroin/Methadone suppresses libido, retarded or failed ejaculation
Amphetamine increases libido
Cocaine is sexually stimulating but also leads to erectile dysfunction and/or priapism
Amyl Nitrite is a vasodilator and an aphrodisiac, but also very accident prone

Gender Identity Disorders

Gender Identity=sense of being male or female
Gender Role=expression of one’s gender identity

Gender Identity Disorder

• Strong, persistent cross-gender identification
• In children, the disturbance is manifested by 4 OR MORE OF THE FOLLOWING:
 Repeatedly stated desire to be, or insistence that he/she is the other sex
 In boys, preference for cross-dressing or simulating female attire
 In girls, insistence on wearing only stereotypical masculine clothing
 Strong, persistent preference for cross-sex roles in make-believe play or
persistent fantasies of being the other sex

 Intense desire to participate in the stereotypical games and pastimes of the
other sex
 Strong preference for playmates of the other sex
• In adolescents and adults, the disturbance is manifested by symptoms such as
stated desire to be the other sex, frequent passing as the other sex, desire to live or
be treated as the other sex, or conviction that he/she has the typical
feelings/reactions of the other sex
Persistent discomfort w/ his/her sex or sense of inappropriateness in the gender role of
that sex. In children: males->assertion that penis or testes are disgusting or will disappear
or assertion that it would be better not to have a penis or aversion toward rough and
tumble play and rejection of male stereotypical play/toys. Females-> reject urinating
sitting, does not want to grow breasts or menstruate, marked aversion toward normative
female clothing. In adolescents and adults: Preoccupation w/ getting rid of primary and
secondary sex characteristics or belief that he/she was born the wrong sex.

Physiologic Abnormalities:
Turner’s (XO) Female, Fibrous or absent ovaries, short stature, webbed neck
Klinefelter’s (XXY) Male, Small testes, breast development
Androgen Insensitivity/Testicular Feminization (XY) Female, Body cells
unresponsive to androgen, undescended testicles
Congenital Adrenal Hyperplasia (XX) Female w/ masculinized genitalia, Adrenal
gland cannot produce adequate cortisone, excessive androgen secreted prenatally

Mood Disorders
Mood=internal emotion
Affect=how mood is expressed

Mood disorders occur more frequently in single, divorced, and separated people
**When diagnosing a mood disorder, it is important to look at mood/affect over time**

Major Depressive Episode: , male=10% prevalence, females=15-20% prevalence

• Depressed mood (50% of cases)
• Diminished interest or pleasure (50% of cases)
• Significant weight loss (5% in a month)
• Change in appetite (80% of cases)
• Insomnia or hypersomnia
• Psychomotor agitation or retardation (restlessness, or slow down)
• Fatigue, loss of energy (97% of cases)
• Feelings of worthlessness
• Excessive or inappropriate guilt
• Diminished ability to think or concentrate
• Suicidal ideation (65% of cases)

Mood congruent delusions are common: guilt, worthlessness, failure, persecution
Dopamine hypoactivity (decreased), Decreased MAO activity
70% of 1st episodes have a life stressor component
½ - ¾ of individual who suffer from a major depressive episode have a 2nd
Mean age of individual 40 yrs., Increased age = increase in frequency and length of episodes
Most individuals have 5-6 episodes over a 20-year period
Untreated episode lasts 6-12 months, Treated lasts 3 months
TX: 75% success rate, drugs/ECT, 4-6 wk trial of antidepressants (fluoxetine)
Nonpsychiatric causes of depression: cancer, thyroid, mono, pneumonia, AIDS, lupus, arthritis,
M.S, Parkinson’s, stroke, steroids, oral contraceptives, drugs

Manic Episode
• Period of abnormally, persistently elevated, expansive or irritable mood FOR 1WEEK
• During the disturbance, THREE OR MORE OF THE FOLLOWING:
 Inflated self-esteem or grandiosity
 Talkative
 Flight of ideas, racing thoughts
 Distractibility
 Increase in goal-directed activity or psychomotor agitation
 Excessive involvement in pleasurable activities w/ potential for painful

Impaired judgment, disorders of form, disorders of thought process

Hypomanic Episode
• Period of persistently elevated, expansive or irritable mood THROUGHOUT 4 DAYS
• During the disturbance, THREE OR MORE OF THE FOLLOWING:
 Inflated self-esteem or grandiosity
 Talkative
 Flight of ideas, racing thoughts
 Distractibility
 Increase in goal-directed activity or psychomotor agitation
 Excessive involvement in pleasurable activities w/ potential for painful

Bipolar I, .4-1.6% prevalence (men=women), mean age of onset 30 years

• Presence of at least one manic episode
• May or may not have had a depressive episode

Manic episode has rapid onset, untreated lasts 3 months, 6-9 months between episodes
1st manic episode usually occurs after 3 major depressive episodes
15% of patients only exhibit mania
40% of individuals have more than 10 episodes of mania
Increased incidence in higher SES
Prognosis worse than that of depression
50% of individuals w/ bipolar have a parent w/ a history of mood disorder

TX: Lithium

Bipolar II, .5% prevalence

• Presence of one or more major depressive episodes
• Presence of at least one hypomanic episode
• There has never been a manic episode

Dysthymic Disorder
• Depressed mood for most of the day, for more days than not FOR 2 YEARS
 Poor appetite or overeating
 Insomnia or hypersomnia
 Low energy or fatigue
 Low self-esteem
 Poor concentration or difficulty making decisions
 Feelings of hopelessness

Cyclothymic Disorder, 1% prevalence

• FOR AT LEAST 2 YEARS, the presence of hypomanic and depressive symptoms

Comorbidity with Borderline Personality Disorder

Minor Depressive Disorder, 1% prevalence

• Depressed mood
• Diminished interest or pleasure
• Significant weight loss (5% in a month)
• Change in appetite
• Insomnia or hypersomnia
• Psychomotor agitation or retardation (restlessness, or slow down)
• Fatigue, loss of energy
• Feelings of worthlessness
• Excessive or inappropriate guilt
• Diminished ability to think or concentrate
• Suicidal ideation

Anxiety Disorders

Fear=normal reaction to known, environmental source of danger
Anxiety=source of danger unknown and/or unrecognized
Neurotransmitters involved=GABA, norepinephrine, serotonin
@ locus ceruleus, raphe nuclei

Generalized Anxiety Disorder, 3-8% prevalence, women:men, 2:1

• Excessive anxiety and worry FOR AT LEAST 6 MONTHS
• Difficulty controlling worry
• Anxiety and worry are associated with 3 OR MORE of the following:
 Restlessness, feeling keyed up or on edge
 Easily fatigued
 Difficulty concentrating
 Irritability
 Muscle tension
 Sleep disturbance

More common in women

Age of onset 30s
TX: Relaxation therapy, benzodiazapines, Buspirone

Obsessive-Compulsive Disorder, 2-3% prevalence, adult men=women, adolescents boy>

• Presence of either obsessions or compulsions
Obsessions: thoughts, impulses, images experienced as intrusive and/or
inappropriate and cause anxiety. Not simply worries about real life problems.
Attempt to ignore, repress or neutralize these thoughts. Recognition that the
obsessions are a product of own mind.
Compulsions: Repetitive behaviors or mental acts that the person feels driven to
perform in response to an obsession according to rigidly applied rules. The
behaviors are aimed at preventing or reducing distress or a dreaded event. They
are not connected in a realistic way with what they are trying to prevent.
• At some point the person recognizes that the obsessions/compulsions are excessive

Often EEG abnormalities

TX: Behavior Therapy, Clomipramine (most effective)

Panic Disorder (coded w/ or w/out Agoraphobia)

• Recurrent unexpected panic attacks (usually last 30 minutes)
• At least one attack has been followed by AT LEAST 1 MONTH OF: persistent concern
of more attacks, worry about the consequences of attack, and or significant change in

Strong genetic component

2X more common in women
Commonly occurs 2X week
50% have mitral valve prolapse
TX: Systematic desensitization, cognitive therapy, antidepressants, Imipramine, Alprazolam

Panic Attack (not a codable disorder)
• Palpitations, pounding heart, sweating, trembling, shaking, shortness of breath, feelings
of choking, check pain or discomfort, nausea, abdominal distress, dizziness, faintness,
derealization or depersonalization, fear of losing control/going crazy, fear of dying,
paresthesias, chills, hot flashes

Agoraphobia (not a codable disorder)

• Anxiety about being in places/situations from which escape might be difficult or help
may be unavailable in the event that a panic attack occurs.
• Situations are avoided or endured w/ marked anxiety about having an attack

Specific Phobia
• Persistent fear cued by the presence or anticipation of a specific object or situation
• Exposure to the stimulus always provokes anxiety response
• Person recognizes that fear is excessive and unreasonable

TX: Systematic desensitization, MAO inhibitors, also propranolol

Social Phobia
• Persistent fear of one or more social or performance situations. Fear being embarrassed or
• Exposure to the feared social situation always provokes anxiety response

Post Traumatic Stress Disorder: 1-3% prevalence

Disturbance is for MORE THAN 1 MONTH
• Exposure to a traumatic event in which the person was confronted with actual or
threatened death or serious injury or threat to integrity of self or others.
• Response involves intense fear, helplessness, or horror
• Event is persistently re-experienced in one or more of the following ways:
 Recurrent, intrusive distressing recollections of event
 Recurrent, distressing dreams of event
 Acting or feeling as if the traumatic event were recurring
 Psychological distress at exposure to internal or external cues that
symbolize or resemble an aspect of traumatic event
 Physiologic reactivity on exposure to internal or external cures that
resemble an aspect of traumatic event
 Persistent avoidance of stimuli associated with the trauma and numbing of
general responsiveness
 Persistent symptoms of increased arousal

TX: short-term psychotherapy, antidepressants, MAO inhibitors

Acute Stress Disorder: MINIMUM OF 2 DAYS, MAXIMUM OF 4 WEEKS

Symptoms similar to PTSD

Psychotic Disorders:
1.5% prevalence, men=women
Bleuler’s 4As: Autism (lack of communication),
Affect (flat),
Associations (loose),
Ambivalence (uncertain)

Schizophrenia: 1% prevalence
*2 or more of the following DURING A 1 MONTH PERIOD, PERSISTING FOR 6 MONTHS*
• Delusions
• Hallucinations
• Disorganized Speech
• Disorganized or catatonic behavior
• Negative symptoms (flat affect, alogia-speech deficiencies, avolition) D1
• Positive symptoms (loose associations, strange behavior, hallucinations, talkative)
D2,3 receptors

Paranoid Type-preoccupation w/ one or more delusions or frequent auditory

hallucination. No disorganized speech, behavior, or inappropriate affect
(better social functioning, older age of onset, difficult to get to treatment)
Disorganized Type-Disorganized speech, behavior, and flat or inappropriate
affect (Worst type, dysfunctional, poor prognosis, onset<25yrs)
Catatonic Type-At least 2 of the following: motoric immobility, excessive motor
activity, extreme negativism or mutism, posturing, echolalia or echopraxia
Undifferentiated Type-Criteria are not met for any of the above
Residual Type-No prominent delusions, hallucinations, disorganized speech or
behavior, but the presence of 2 or more schizophrenic symptoms in
attenuated form (odd beliefs, unusual perceptions)

Good Prognosis=Late onset, precipitating factors, acute onset, good premorbid history of
functioning, mood disorder symptoms, married, family history of mood disorders, good support
symptoms, positive symptoms
Poor Prognosis=Young onset, no precipitating factors, insidious onset, poor premorbid
functioning, withdrawn, autistic behavior, single, divorced, family history of schiz., poor support
system, negative symptoms, multiple relapses, “High Expressed Emotion” (pressures in family)

Male onset=15-25yrs old, Female=25-35yrs old

Higher population density=increased rates of schizophrenia
More individual w/ schizophrenia born during cold weather months
“Downward Drift” = schizophrenia more common in lower S.E.S because they move into lower
SES areas as a result of illness
Hyperactive dopaminergic system, Decreased GABAIncreased dopamine
Memory intact, Oriented to person, place, time
Genetic marker: Long arm chromosome 5, 11, 18

Short arm 9, X
TX: Behavioral, Family, and Individual Therapy, Antipsychotics/Neuroleptics, Side Effects of
Neuroleptics: weight gain, impotence, extrapyramidal signs, Extrapyramidal (tremor, akinesia,
rigidity, muscle spasms, tardive dyskinesia)
**Clozapine-no extrapyramidal signs**

Brief Psychotic Disorder

• Delusions, hallucinations, disorganized speech and/or behavior

Post – partum onset: 1 in 1,000 deliveries

Schizophreniform Disorder
• The criteria for schizophrenia are met FOR AT LEAST 1 MONTH BUT < 6

Shizoaffective Disorder
• Major depressive episode, manic episode, or mixed episode with Schizophrenia
• Delusions or hallucinations for AT LEAST 2 WEEKS W/OUT MOOD SYMPTOMS

Delusional Disorder, .025-.03% prevalence

• Nonbizarre delusions FOR AT LEAST 1 MONTH
• Criteria for schizophrenia have never been met
Erotomanic type, Grandiose type, Jealous type, Persecutory type, Somatic type,
Mixed type, Unspecified type

Simple Schizophrenia
• Decline in functioning, gradual appearance and deepening of negative symptoms, no
other schizophrenic symptoms met

Shared Psychotic Disorder, “Folie a deux”

• Same or similar delusion develops in a person in the context of a close relationship
with another person who has an already established delusion.

Personality Disorders (coded on Axis II)

These disorders are set by 18 years of age
Long-standing, rigid, unsuitable way of dealing with others
Often unaware of problem, don’t seek treatment
TX: Individual and group psychotherapy, and drugs would be prescribed to treat the
associated symptoms (rage, anxiety, depression, etc.)

Paranoid Personality Disorder, .5-2.5% prevalence, more common in males

• Pervasive distrust and suspiciousness of others,

 Suspects that others are exploiting, harming or deceiving him/her
 Preoccupied with unjustified doubts about the loyalty of friends/family
 Reluctance to confide in others
 Reads hidden meaning into benign remarks or events
 Persistently bears grudges
 Perceives attacks on character or reputation not apparent to others
 Recurrent suspicions, w/out justification, regarding fidelity of partner

Rarely seek treatment, when in treatment will appear undistressed

Trust and tolerance of intimacy are difficult for patient
TX: Psychotherapy: be straightforward and honest, antianxiety and/or antipsychotic

Schizoid Personality Disorder, more common in males

• Pervasive pattern of detachment from social relationships and a restricted range of
expressing emotions in interpersonal settings
 Neither desires nor enjoys close relationships, including family
 Almost always chooses solitary activities
 Has little, if any, interest in having sexual experiences w/ others
 Takes pleasure in few, if any, activities
 Lacks close friends or confidants
 Indifferent to praise or criticism
 Emotional coldness, detachment, or flattened affect

Often seen by others as eccentric, isolated, or lonely

TX: Psychotherapy: may become devoted patients, be straightforward and honest, build trust

Schizotypal Personality Disorder, 3% prevalence

• Pervasive pattern of social and interpersonal deficits marked by acute discomfort with
and reduced capacity for close relationships as well as by cognitive or perceptual
distortions and eccentricities of behavior
 Ideas of reference (excluding delusions of reference)
 Odd beliefs, magical thinking that influence behavior
 Unusual perceptual experiences, including bodily illusions
 Odd thinking and speech
 Suspiciousness or paranoid ideation
 Inappropriate or constricted affect
 Odd, eccentric, peculiar behavior and / or appearance
 Lack of close friends
 Excessive social anxiety (w/ paranoid fears) that doesn’t diminish with

TX: Psychotherapy: Patients have peculiar patterns of thinking, therapists must not ridicule or
judge these thoughts/activities, antipsychotic

Antisocial Personality Disorder, more common in males =3% prevalence, female=1%

• Pervasive pattern of disregard for and violation of the rights of others
 Failure to conform to social norms w/ respect to lawful behavior
 Deceitfulness, repeated lying, use of aliases, conning
 Impulsivity, failure to plan ahead
 Irritability and aggressiveness
 Reckless disregard for safety of self or others
 Consistent irresponsibility
 Lack of remorse
• Individual is at least 18, with evidence of conduct disorder prior to age 15

Patients may seem normal, even charming

TX: Psychotherapy: self-help groups, firm limits are essential, must frustrate patients desire to
run from honest human encounters

Borderline Personality Disorder, 1-2% prevalence, 2X more common in females

• Pervasive pattern of instability of interpersonal relationships, affect, and self-image, as
well as marked impulsivity
 Frantic efforts to avoid real or imagined abandonment
 Unstable and intense interpersonal relationships w/ extremes of
idealization and devaluation
 Identity disturbance, unstable self-image or sense of self
 Potentially damaging impulsivity in spending, sex, substance abuse,
driving and/or eating
 Recurrent suicide behavior
 Affective instability due to marked reactivity of mood
 Chronic feelings of emptiness
 Inappropriate, intense anger, difficulty controlling anger
 Stress related paranoid ideation or severe dissociative symptoms

Crisis Addict, often attempt suicide for attention, to manipulate others, and accidentally succeed
Poor prognosis
TX: Psychotherapy: Problems: patients regress easily, act out impulses, transference, splitting,
therefore, reality-oriented approach is most common. They do best in hospital setting.
Antipsychotics, antidepressants, MAOIs

Histrionic Personality Disorder, 2-3% prevalence, more common in females

• Pervasive pattern of excessive emotionality and attention seeking
 Uncomfortable in situations in which he/she is not center of attention

 Interactions w/ others is sexually seductive/provocative
 Rapidly shifting, shallow expressions of emotion
 Use of physical appearance to draw attention to self
 Style of speech is excessively impressionistic and lacking in detail
 Self-dramatic, theatrical, exaggerated expression of emotion
 Easily influenced by others or circumstances
 Considers relationships to be more intimate than actually are

TX: Psychotherapy: As these patients are unaware of their own feelings, clarification of their
inner feelings is important

Narcissistic Personality Disorder, <1% prevalence

• Pervasive pattern of grandiosity, need for admiration, and lack of empathy
 Grandiose sense of self-importance
 Preoccupied with fantasies of unlimited success, power, brilliance, beauty
 Believes he/she is special, unique, only to be understood by other special
 Requires excessive admiration
 Sense of entitlement
 Interpersonally exploitive
 Lacks empathy
 Envious of others, and believes others are envious of him/her
 Arrogant, haughty behavior/attitudes

TX: Individuals are chronic, difficult to treat b/c treatment=blows to their narcissism, Lithium
and antidepressants

Avoidant Personality Disorder, 1-10% prevalence, more common in females

• Pervasive pattern of social inhibition, feelings of inadequacy, and hypersensitivity to
negative evaluation
 Avoids occupational activities that involve interpersonal contact in fear or
criticism, disapproval, or rejection
 Unwilling to get involved with people unless certain of being liked
 Shows restrain w/in intimate relationship in fear of being shamed or
 Preoccupied w/ being criticized or rejected in social situations
 Inhibited in new interpersonal situations b/c of feelings of inadequacy
 Views self as socially inept, personally unappealing or inferior to others
 Unusually reluctant to take personal risks or to engage in new activities

TX: Psychotherapy: depends on solid alliance w/ patient, trust and acceptance, encourage risk-
taking despite fear of humiliation/rejection, Beta Blockers

Dependent Personality Disorder, more common in females
• Pervasive, excessive need to be taken care of that leads to submissive, clinging behaviors
and fears of separation
 Difficulty making everyday decisions w/out advice and reassurance from
 Needs others to assume responsibility for most areas of his/her life
 Difficulty expressing disagreement w/ others for fear of loss of
 Difficulty initiating projects or doing things on his/her own (not lack of
 Goes to excessive lengths to get nurturance and support from others
 Uncomfortable or helpless when alone b/c exaggerated fears of inability to
care for self
 When a close relationship ends, urgently seeks another for source of
 Unrealistically preoccupied w/ fears of being left to take care of self

TX: Psychotherapy: often successful, w/ support of therapist the patient becomes more
independent, self-reliant, assertive. Beware of how this will affect pathological relationships

Obsessive-Compulsive Personality Disorder, more common in males, often oldest child

• Preoccupation with orderliness, perfectionism, and mental and interpersonal control at the
expense of flexibility, openness, and efficiency
 Preoccupied w/ details, rules, lists, order, organization, schedules to the
extent that the major point of activity is lost
 Shows perfectionism that interferes w/ task completion
 Excessively devoted to work and productivity to the exclusion of
 Over conscientious, scrupulous, and inflexible about
 Unable to discard worn-out or worthless objects
 Reluctant to delegate tasks or work with others
 Miserly spending style toward self and others
 Rigid and stubborn

TX: Psychotherapy: often aware of suffering, seek treatment on their own. Free association and
non-directive therapy, Benzodiazepines (Clonazepam)

Passive Aggressive Personality Disorder

• Pattern of negativistic attitudes and passive resistance to demands for adequate
 Passively resists fulfilling routine social/occupational tasks
 Complains of being misunderstood / unappreciated by others

 Sullen, argumentative
 Unreasonably criticizes and scorns authority
 Envy and resentment toward those more fortunate
 Voices exaggerated, persistent complaints of personal misfortune
 Alternates between hostile defiance and contrition

Somatoform Disorders
These individuals truly believe that they are sick

Somatization Disorder, .1-.5% prevalence, women:men=20:5

• History of many physical complaints beginning BEFORE AGE 30 that occur over a
many years and result in treatment being sought or significant impairment
• Each of the following must be met, w/ individual symptoms at any time during
 Four pain symptoms
 Two gastrointestinal symptoms
 One sexual symptom
 One pseudoneuronalogical symptom
• Symptoms are not explained by a know medical condition

TX: Difficult to treat, Individual and group psychotherapy, anxiolytics, hypnosis, consistent
physician who views symptoms as communications and helps patient see link w/ psychology

Conversion Disorder, .002% prevalence, women:men=2:1

• One or more symptoms or deficits affecting voluntary motor or sensory function that
suggest neurological or other general medical condition
• Psychological factors are associated with symptom b/c symptom is preceded by conflicts
or stressors
• Symptom is not intentionally produced
• Symptom cannot be explained by general medical condition

RepressionConversionPhysical Symptom
TX: 90% cure in < month, insight-oriented supportive or behavioral therapy, hypnosis,
anxiolytics, relaxation exercises, lorazepam, amytal

Hypochondriasis - Duration of disturbance is for AT LEAST 6 MONTHS

• Preoccupation with fears of having or getting a serious disease based on misinterpretation
of bodily symptoms
• Preoccupation persists despite medical evaluation and reassurance

Onset between 20-30 years of age, more common in blacks than whites
TX: Patients are usually resistant to treatment, group psychotherapy, frequent regularly
scheduled physical exams provide reassurance that doctor has not abandoned patient

Body Dysmorphic Disorder
• Preoccupation w/ imagined defect in appearance

Age of onset 15-20 years, more common in women than men, unmarried
Comorbidity w/ major depressive episode, anxiety disorder, psychotic disorder
TX: SSRIs, tricyclics, MAOs

Pain Disorder
• Pain in one or more anatomical sites
• Psychological factors are judged to have a role in onset, severity, exacerbation and
maintenance of pain
• Pain is not intentionally produced

Diagnoses twice as frequently in women than men

TX: psychotherapy: address rehabilitation, discuss psychological factors

Factitious Disorders
Factitious Disorder, more frequent in men
• Intentional production of physical or psychological signs or symptoms
• Motivation is to assume the sick role
• External incentives for the behavior are absent

“Malingering” (not a codable disorder)

Production of signs and/or symptoms are for obvious, recognizable environmental goals
Usually stop producing signs/symptoms when it’s no longer profitable or is too risky

Dissociative Disorders
Defense against trauma and anxiety
Important differentials for all dissociative disorders: Dementia, Delirium, ECT, Epilepsy,
Head trauma, Substance abuse

Dissociative Amnesia, very common, women>men

• One or more episodes of inability to recall important personal info, usually of
traumatic/stressful nature, that is too extensive to be explained by forgetfulness

Most common dissociative disorder

More common in women
Differential: head trauma (retrograde amnesia) vs. anterograde amnesia of dissociative disorders,
organic brain disorder (sense of self will not be lost, will be oriented to self)
TX: protect patient, recovery may be traumatic (there’s a reason they forget), hypnosis,
amobarbital sodium interviews, long-term psychotherapy

Dissociative Fuge
• Sudden, unexpected travel away from home or customary place of work, w/
inability to recall one’s past
• Confusion about personal identity or assumption of new identity

Usually occurs during or right after personal crisis, lasts for a few hours/days (recurrence rare)
Individuals w/ borderline, histrionic personalities are more prone
TX: Supportive treatment understanding of cause, hypnosis, amital

Dissociate Identity Disorder, women:men 1:20

• Presence of 2 or more distinct identities or personality states (each w/ own sense of
self: id, ego, superego)
• At least 2 of these identities take control of person’s behavior
• Inability to recall important personal info that can’t be explained by forgetting

Onset in adolescence, early adulthood as a result of severe childhood trauma

Earlier onset = worse prognosis
TX: Psychotherapy w/ special skills, Find the trigger that precipitates switch, anticipate switch
and interveneAssimilate personalities into one whole individual.
Ethical Question arises: Which personalities get extinguished, which get assimilated?

Depersonalization Disorder, women=men, rare >40years

• Recurrent experiences of feeling detached from one’s metal processes or body, as if
“outside of oneself.”
• Reality testing remains intact during depersonalization

Causes: sensory deprivation, brain tumors, emotional trauma, substances, anxiety, depression
TX: Anticholinergic drugs, barbituates

Cognitive Disorders
Caused primarily by abnormalities in brain chemistry, structure, and/or physiology

• Disturbance of consciousness (reduced clarity of awareness of environment) w/ reduced
ability to focus, sustain, or shift attention
• Change in cognition (memory deficit, disorientation, language disturbance)
• Disturbance develops over a short period of time (hours to days) and tends to fluctuate
during the course of a day

Hallmark: Impaired consciousness

Impairment is usually worse at night and in the early am, “Diurnal variability”

Often visual illusions and/or hallucinations
3 Month mortality rate: 23-33%
Causes: cerebral, somatic, external, pharmacologic, CNS dysfunction
Major neurotransmitteracetylcholine, Neuroanatomical areareticular formation
Most common psychiatric disorder seen in patients admitted to medical/surgical units
1/3 of ICU/Surgical patients are suffering from delirium
TX: identify and remove causative factors, recedes in 3-7 days, if psychosis: Haloperidol, if
insomnia: benzodiazepines w/ short ½ lives

• Development of multiple cognitive deficits manifested by memory impairment and
cognitive disturbances (aphasia, apraxia, agnosia, disturbance of executive functioning)

Hallmark: Memory Loss

Most common in the elderly, 15% prevalence in individuals > 65yrs
2/3 of cases are Dementia of the Alzheimer’s Type, 5% of dementia’s are Pick’s Disease, 10%
are multi-infarct, Korsakoff’s relatively rare dementia
Loss of intellectual ability, memory loss and impaired functioning
Causes: reduction in choline aceytltransferase, alcohol (Karsakoff’s), nervous system infections,
Alzeheimer’s: hypoactive acetylcholine & norepinephrine
Alzheimer’s risk factors: female, 1st degree relative w/ it, history of head injury, Down’s synd.
Subcortical Dementia: Huntington’s Disease, Parkinson’s, HIV
2/3 of HIV patients suffer from dementia
Brain of dementia patients -cortical atrophy, inflammation, demyelination,
basal ganglia most affected area
TX: 15% of cases are reversible, psychotherapy, pharmacology to treat associated symptoms,
provide structured environment, proper diet, exercise

Delirium vs. Dementia

Consciousness impaired Consciousness not impaired
Stupor or agitation Normal level of arousal
Develops quickly Develops slow, insidiously
Frequently Reversible Often Irreversible

Substance Abuse Disorders

Most common in 18-25 year olds
3X more common in males

Psychoactive Substance Dependence=intoxication, tolerance and withdrawal symptoms which

continue for at least 1 MONTH or intermittently over an extended period of time

Psychoactive Substance Abuse=psychoactive substance use for at least 1 MONTH or

intermittently over an extended period of time. Most common in people just starting to use drugs
that do not have severe withdrawal symptoms

Polysubstance Dependence=Repeated use of at least 3 types of psychoactive drugs for at least 6

Tolerance=need for increased amounts for same effect

Cross tolerance=tolerance development for 1 drug because of use of another

¾ of US adult population uses caffeine

1/3 of US adult population smokes cigarettes
80% of individuals who quit smoking relapse w/in the first 2 years
Alcohol is used most in 21-34 year olds
13% of adults abuse alcohol or become alcohol dependent
Male alcoholics more common than female
Later onset of alcoholism in women
Highest prevalence of alcoholism in N.E states
Alcoholism is 4X more prevalent in children of alcoholics
Sons have a greater risk than daughters of becoming alcoholics

Substance Withdrawal Symptoms

Alcohol Tremor, tachycardia, hypertension, malaise, nausea, seizure,
delirium, tremens (DTs)
Amphetamines Post use “crash” includes anxiety, lethargy, headache, stomach
cramps, hunger, severe depression
Barbiturates Anxiety, seizures, delirium, life-threatening cardiovascular
Benzodiazapines Long-lasting anxiety, convulsions, tremor, insomnia
Caffeine Headache, lethargy, depression, weight gain
Cocaine Hypersomnolence, fatigue, depression, malaise, severe cravings
(2-4 days after last dose)
Nicotine Irritability, headache, anxiety, weight gain
Opiods Anxiety, insomnia, anorexia, sweating, fever, rhinorrhea,
piloerection, nausea, stomach cramps

Psychiatric Emergencies
10% of ER visits are psychiatric emergencies
Presentation may be overt or covert, significant disturbance of cognition or mood (suicidal,
depressed, severe obsessional thoughts, acute anxiety, phobias)

8th leading cause of death in the US, 30,000 deaths per year
2nd leading cause of death among 15-24 year olds
Men commit suicide 3X more often than women
Women attempt suicide 4X more often than men
25% of suicides are by the elderly
80% of suicides are secondary to depression

Cancer patients tend to commit suicide w/in first year after diagnosis
Indicators of high risk: age > 45 yrs, male sex, single/divorced/widowed, unemployed,
chaotic/conflicted family/personal relationships, alcohol/drug abuse, prior suicide
attempts (highest indicator), hypochondriachal, psychosis, severe personality disorder,
strong wish to die, available methods, plan for suicide, family history, poor achievement,
poor insight, social isolation,
Whites commit suicide more frequently, as do Jews & Protestants vs. Catholics
Professionals, esp. psychiatrists, dentists, law enforcement, lawyers, musicians greater
Hospitalize ifimpulsive, lack social support, presence of specific plan

Outwardly or inwardly directed destructive behavior
Environment, biology and psychology interplay, to cause distress for individual
Risk factors: past history of violence, forensic history, childhood history of abuse,
possession/access to weapon, history of psychosis, current psychotic state,
alcohol/substance abuse, cognitive state, physical illness
TX: haldol, benzodiazepines, amobarbital, lithium

Psychosocial Theories of Suicide/Violence

Egoistic (not integrated into a social group)
Altruistic (excessive integration)
Anomic (disturbance in integration, normal balance disturbed)
self –hatredanger toward love object is turned back against self
Suicide=inverted homicide, 3 components of hostility in suicidewish to kill,
wish to be killed, wish to die

Psychoanalytic Theory: Sigmund Freud
Forces motivating behavior are derived from unconscious mental processes, sexual and
aggressive drives motivate activities of the mind
Repression=force that keeps unconscious processes out of consciousness
Unconscious mind=repressed thoughts and feelings, primary process thinking (primitive
drives, wishes and pleasure
Preconscious mind=secondary process thinking (logical, associated w/ reality)
Conscious mind=operates w/ preconscious, no access to unconscious
Id=sexual and aggressive drives, pleasure principle
Ego=maintains relationship to outside world, controls expression of instinctual drives to
adapt to external reality

Superego=moral values and conscience, controls id impulses
Defense mechanisms=unconscious mental techniques used to decrease anxiety, and
maintain self-esteem, safety, equilibrium (acting out, denial, displacement, dissociation,
identification, intellectualization, isolation of affect, projection, rationalization, reaction
formation, regression, repression, splitting, altruism, humor, sublimation, suppression)


Classical Psychoanalysis-
Based on Freud’s Psychoanalytic Theory
3-6 years, 4 times per week, 45-50 minute sessions
Purpose to recover and integrate into an individual’s personality, those experiences
repressed in the unconscious
Major technique is free association (say whatever comes to mind), couch promotes f.a.
Fundamental Rule: patient must be completely honest (doesn’t always happen)
Therapeutic Alliance: mutual trust, cooperation, honesty
Intensive focus on transference=patient’s unconscious feelings from the past are
displaced onto and experienced w/ therapist
Countertransference=therapist unconsciously experiences feeling about past w/ patient
Therapist’s (tabula rasa) role is to interpret material produced in free association using
“free-floating attention”
Dreams (roadway into the unconscious): manifest content (what’s reported), latent
content (unconscious meaning)
Analysis of defense mechanisms that fend off awareness of unconscious conflicts
Therapist provides well-timed interpretations, of which transference is major frame of
Indicators: significant suffering (motivation), wish to understand self, tolerance for
frustration/anxiety/strong affect, mature superego (honest), ave. or > IQ, psychologically

Psychoanalytic Psychotherapy: Modified Psychoanalysis

Insight-oriented (Expressive) Psychotherapy:
1-3 times per week, 45-50 minute sessions
Focus on current functioning vs. reconstruction of childhood events (Freud)
Interpretation, Confrontation, Clarification used to become aware of unconscious
determinants of behavior

Supportive psychotherapy:
Therapist as authority figure during time of illness, turmoil, temporary
Therapist as warm, friendly, strong leadership, partial gratification of dependency
needs, help in developing pleasurable activities, rest/diversion
Goal: help patient feel secure, accepted, protected, encouraged, safe, not anxious
Talking is done for relief, not for insight

Brief psychotherapy

Brief in Focus

Derived from a combo of psychoanalytic and learning theories
Increased popularity b/c of pressure to contain health care costs
Clear-cut selection/rejection criteria: highly motivated, able to deal w/ psych. concepts,
concentrate on / resolve conflict, develop therapeutic alliance quickly
20-30 sessions to clarify nature of defense/anxiety/impulse

12 interviews, no explicit candidates
Goal: to resolve present/chronically endured pain & negative self-image

Crisis intervention
Therapeutic and preventative
Crisis Intervention=immediate responses to an immediate situation, as well as long-term
development of psychological adaptation to prevent future problems
Crisis=painful state in response to hazardous events, may last hours-weeks
Crisis 1.anxiety/tension rise
2.problem-solving mechanisms kick in (adaptive/maladaptive)
maladaptivepain intensifies, crisis deepens, regressive deterioration
TX: Rapidly establish rapport, reassurance, suggestion, environmental manipulation,
psychotropic meds
Resolve crisis and build skills to prevent future crisis

Biological Treatments

Electroconvulsive Therapy (ECT): Induction of a generalized seizure by passing an

electric current across the brain
Most commonly used to treat major depression, also acute mania, and schizophrenia w/
acute, catatonic, or affective symptoms
Improvement after the first few treatments, Max response after 5-10 treatments
Problems=retrograde amnesia for past events (will resolve 6 months after treatments)

Transcranial Magnetic Stimulation

Localized magnetic field generated
More focused application than ECT
Indicators: depression (left prefrontal cortex), anxiety (l.p. cortex), Parkinson’s (motor c.)
May cause seizures when given in high intensities

Surgical modification of brain, Lesion-specific brain regions
Used in severely ill patients

Autonomic nervous system can come under voluntary control through operant
Patients get info on involuntary biologic function through instruments, and learn to
EMG-electric potential of muscle fibers

EEG-alpha waves in relaxed state
GRS-galvanic skin response gauge-skin conductivity
Thermistor-skin temp
Applications: asthma, cardiac arrhythmias, encopresis/enuresis, ADHD, epilepsy,
migranes, hypertension

Antipsychotics (Neuroleptics): Treat Schizophrenia

Low potency=non-neurologic adverse effects (orthostatic hypotension, increased prolactin,

leukopenia, agranulocytosis, jaundice, skin eruptions, photosensitivity, retinal pigmentation,
constipation, dry mouth)
High potency=neurologic adverse effects (Parkinsonian effects, Tardive dyskinesia, neuroleptic
malignant syndrome, akathisia, dystonias, seizures)

Phenothiazines: D2 Blockers, Effective against positive symptoms

Thioridazine (Mellaril): Low potency
Chlorpromazine (Thorazine): Low potency
Perphenazine (Trilafon): High potency
Trifluoperazine (Stelazine): High potency
Thioxanthenes: D2 Blockers, Effective against positive symptoms
Butyrophenones: D2 Blockers, Effective against positive symptoms
Haloperidol (Haldol): High potency
Benziosoxasole: 5-HT2 Receptor Antagonist, Effective against negative symptoms
Risperidone (Risperidol): Low potency

Clozapine (Clozaril): when other neuroleptics are causing adverse effects

Works on sertonergic system, and D1 receptor agonist
Used to treat negative symptoms
No neurologic adverse effects, May develop agranulocytosis and/or seizures

Heterocyclics (Tricyclics):*Primary drugs to treat depression*, Block reuptake of
norepinephrine and serotonin, Also block acetylcholine and histamine receptors to
produce anticholinergic effects (dry mouth, blurred vision, urine retention, constipation,
sedation), Overdose can be fatal.
Imipramine (Tofranil): Strongly anticholinergic, more likely to cause orthostatic
Clincial use: Panic disorder w/ agoraphobia, eneuresis, anorexia nervosa, bulimia.
Clomipramine (Anafranil): Most specific for serotonin.
Clinical use: Obsessive-compulsive disorder .
Desipramine (Norpramin): Least sedating, least anticholinergic.
Clinical use: Depression in the elderly, anorexia nervosa, bulimia.
Amitriptyline (Elavil): Strongly sedating and anticholinergic.

Clinical use: Depresion with insomnia.
Nortriptyline (Pamelor): Least likely to cause orthostatic hypotension.
Clincal use: Depression in cardiac patients and the elderly.
Amoxapine (Asendin): Parkinsonian symptoms, galactorrhea, sex dysfunction,
most dangerous in overdose.
Clinical use: Depression w/ psychotic features.
Doxepin (Sinequan, Adapin): Strongly sedating and anticholinergic.
Clinical use: Generalized anxiety disorder, peptic ulcer disease.

Monoamine Oxidase Inhibitors (MAOIs): Use to treat Eating disorders, pain

syndrome, agoraphobia w/ panic attack, PTSD
Increase Norepinephrine and serotonin availability
Safe if dietary precautions are taken (beer/wine, beans, cheese, liver, orange pulp, pickled
meats hypertensive crisis)
Other side effects: anticholinergic, sedation, cardiac complications
MAO-A: serotonin and norepinephrine
MAO-B: dopamine

Serotonin Selective Reuptake Inhibitors (SSRIs): Selectively block reuptake of

serotonin, little effect on dopamine and/or norepinephrine
Minimal anticholinergic and cardiovascular adverse effects, may cause weight loss
Setraline (Zoloft)
Paroxetine (Paxil)

Sympathomimetic Agents:
Amphetamines: Used in treatment-resistant individuals at risk from adverse
effects of other antidepressants

Other Antidepressants:
Trazodone (Desyrel): safer antidepressant, used as adjunct to tricyclics
Alprazolam (Xanax): antidepressant activity, but used to treat anxiety

Drugs to treat mania:

Lithium: Adverse effects: renal dysfunction, cardiac conduction abnormalities, gastric
distress, tremor, mild cognitive impairment, hypothyroidism, congenital anomalies
Carbamazepine: Adverse effects: aplastic anemia, agranulocytosis
Valproic Acid (Depakene, Depakote): useful in rapid cycling bipolar treatment
Clonazepam (Klonopin)

Antianxiety Agents (Anxiolytics):

Benzodiazepine: short, intermediate, or long-acting, common SE = sedation, also blurred
vision, weakness, nausea, vomiting. Tolerance and dependence develop w/ chronic use
Midazolam (Versed): Short-acting, also used for anesthesia
Oxaxepam (Serax): Short-acting, also used for alcohol withdrawal
Triazolam (Halcion): Short-acting, also used for insomnia

Alprazolam (Xanax): Intermediate-acting, also antidepressant, panic disorder,
social phobia.
Clonazepam (Klonopin): Intermediate-acting, also for seizures, mania, panic
disorder, social phobia.
Lorazepam (Ativan): Intermediate-acting, also for psychotic agitation
Chlordiazepoxide (Librium): Long-acting, also for alcohol withdrawal
Diazepam (Valium): Long-acting, also a muscle relaxant, and analgesia
Flurazepam (Dalmane): Long-acting, also for insomnia
Halazepam (Paxipam): Long-acting
Prazepam (Centrax): Long-acting
Temazepam (Restoril): Long-acting, also for insomnia
Barbiturates-greater potential for abuse (used less frequently), lower therapeutic index,
SE=sedation, respiratory depression, fatal overdose, tolerance and dependence develop
w/ chronic use
Carbamates- great potential for abuse and dependence, used only when unable to use
Azaspirodecanediones, unrelated to benzodiazepines, nonsedating, not associated w/
dependence, withdrawal or abuse
Buspirone (BuSpar)

Research / Epidemiology / Statistics

Incidence=Number of new individuals that develop an illness in a give time period

Prospective Study (Cohort Study):

Step 1: Identify population (cohort) which is free of illness at start of study
Step 2: Assess exposure to risk factor
Step 3: Compare exposed and nonexposed members of cohort to see who gets sick
Concurrent Prospective Study- taking place in the present time
Nonconcurrent- some activities have taken place in past
Clinical Treatment Trials-prospective study where cohort getting 1 treatment is
compared w/ cohort receiving different or placebo treatment

Advantages= No recall necessary, Incidence determined, Relative risk is accurate

Disadvantages= Long time required, costly, common diseases only, volunteers needed (results
may not be generalized), large number of subjects, attrition problems

Retrospective Studies (Case-Control Study)

Obtain and compare info on prior exposure to risk factors of subjects who have the
disorder (cases) and subjects who don’t have the disorder (controls)

Advantages= short study time, inexpensive, suitable for rare disease, no subject volunteer, small
number of subjects, no attrition problems
Disadvantages=control group susceptible to bias in selection, biased recall possible, can’t
determine incidence

Cross-Sectional Studies
Provide info on possible risk factors and health status of a group of individuals at one
specific point in time

Case Report:
Brief, objective report of a clinical characteristic or outcome from a single clinical subject
or event
Provides first report of unexpected findings, hypothesis for testing, definitions for further

Case Series Report:

Objective report of a clinical characteristic or outcome from a group of clinical subjects
Conclusions are limited b/c there is no comparison group w/in study.

Relative Risk
Compares incidence rate of disorder of exposed individuals w/ incidence rate of disorder
in unexposed individuals. E.g.
R.R = Incidence rate of cancer among smokers / rate among nonsmokers
Can be calculated ONLY for prospective studies

Attributable Risk
Useful for determining what would happen in a study population if the risk factor was
Incidence rate of the illness in nonexposed individuals is subtracted from those who have
been exposed
A.R= incidence rate of lung cancer in smokers - incidence in nonsmokers

Odds Ratio
Estimate of relative risk when incidence rate is not available
How much higher the risk is in exposed individuals vs. nonexposed
Calculated for retrospective (case-control) studies


Odds Ratio = (A)(D) / (B)(C)

Exposed Nonexposed
Diseased A B
NonDiseased C D

Reliability=reproducibility of results (interrater, test-retest)

Efficacy: describes true treatment/intervention effect under ideal conditions
Effectiveness: describes true treatment/intervention effect under clinical conditions/routine


Validity=measure of whether test assesses what it was designed to test
Sensitivity and Specificity are components of validity
Sensitivity (How well a test identifies truly ill people) = A / A+C
Specificity (How well a test identifies truly well people) = D / B+D

Predictive Value=measure of the percentage of test results that match the actual diagnosis
Positive Predictive Value: (Probability that an individual w/ a positive test actually has the
illness) = A / A+B
Negative Predictive Value (Probability that a person w/ a negative test is actually well)
= D / C+D
Prevalence (Number of individuals in a population who have an illness)

Disease State
Test Results Present Absent Total Patients
Positive A B A+B
True Positive False Positive
Negative C D C+D
False Negative True Negative
Total Patients A+C B+D GRAND TOTAL

Statistical Tests
t-test-difference between means of two samples
Analysis of variance-differences between mean of more than two samples
One-way (one variable)
Two-way (two variables)
Chi-squared test-differences between frequencies in a sample
Correlation-mutual relationship between two continuous variables, (-1 and +1)
Multiple regression-relationship between many measures

Normal distribution: mean, median, mode are equal

Positively skewed distribution: scores cluster toward low end
Negatively skewed distribution: scores cluster toward high end

Hypothesis testing
Null hypothesis: says there is no difference between two groups (postulated to be
different in hypothesis)
Type I error: null hypothesis is rejected although it is true
Type II error: null hypothesis is not rejected and it is false
p (probability): chance of a type I error
p < .05 = type I error unlikely, statistically significant

Psychological Testing

Objective Test=Easily scored, statistically analyzed (MMPI)
Minnesota Multiphasic Personality Inventory: hypochondriasis, depression, hysteria,
psychopathology, masculinity/femininity, paranoia, psychastenia(anxiety),
schizophrenia, hypomania, social distance
Projective Test=Subject interprets questions, responses are based on motivational state and
defense mechanisms (Rorschach Inkblot, Thematic Apperception Test, Sentence Completion
Test, Draw-A-Person Test)
Rorschach: though disorders, nature of defenses
Thematic Apperception Test (TAT): make story based on pictureemotions/conflicts
that are out of awareness
Test-Battery=Tests functioning in a number of areas (Halstead-Reitan Battery)
Halstead-Reitan Battery (HRB): presence/location/effect of brain lesions
Luria-Nebraska Neuropsychological Battery (LNNB): left/right cerebral dominance,
specific types of brain dysfunction (i.e. dyslexia)
Intelligence Test=measurement of individual’s ability to reason, manage abstract concepts,
assimilate facts, recall, analyze/organize info, and manage new situations
Stanford Binet Scale: Used to test general intellectual ability btwn 2-18yrs
IQ = mental age:chronologic age X 100
Wechsler Intelligence Tests: Most commonly used IQ test
WAIS-R: Wechsler Adult Intelligence Scale Revised 16-75 years
WISC-R: 6-16 ½ years
WPPSI: 4-6 ½ years