Topics on exams

non-bizarre) to impossible (bizarre)

– When non-bizarre, may need collateral

information to confirm or refute beliefs

Common Delusional Themes

• Persecution/Paranoia

• Passivity and Control, Reference

• Jealousy

• Grandiosity

• Hyper-religiosity

• Somatic

• Erotomanic

Persecutory Delusions

• These individuals tend to be

hypervigilant

• Fine line between Paranoid

Personality Disorder and delusional

paranoia.

13

Common Paranoid Themes

• Personal items have been stolen or

tampered with while patient is away

• Being poisoned or drugged

• Reputation has been ruined or maligned

• Being followed, monitored

Grandiose Delusions

• Impossibly great wealth, fame, power,

privilege, or ability

• Can have religious theme (special

connection with, or mission from God)

Grandiose Delusions

• Very self-referential, egocentriceverything

happening around them

must have something to do with them

• Narcissistic personalities are not

delusional- their self-proclaimed abilities

are within the realm of possibility

Delusions of Jealousy

• Unfounded conviction that spouse or

lover is unfaithful

14

Erotomanic Delusions

• Conviction that someone of higher

social status (often famous) is in love

with them

• Can be nuisance to public figures

• More often in women

Somatic Delusions

• Aka Hypochondriacal Delusions

• Examples include:

– Delusions of odor: patient is convinced they

smell foul

– Delusion of infestation

– Delusion of appearance (body

dysmorphism)

Delusions of Passivity or Control

• Thought Broadcasting

• Thought Insertion

• Thought Withdrawal

• Delusion of Control- submission to an

external controlling force

Delusions of Reference

• Ascribing personal meaning to

innocuous stimuli

• Often involves TV, newspapers, or the

radio delivering special messages for

patient

• Ideas of Reference: Same thing, but

not held with same conviction

15

Delusion vs. Overvalued Idea

• Overvalued ideas are similar to

delusions but:

– Held with less conviction

– Usually less absurd

• Beliefs become “overvalued” when they

preoccupy the person’s thoughts

– (ex. superstitions or magical thinking)
hallucination

Illusion

Perceptual Abnormalities

• Illusions

• Hallucinations

• Derealization/ Depersonalization

• Déjà vu, Jame Vu

Illusions

• Misperceptions of external sensory

stimuli

• Common manifestations of an “organic”

psychosis (due to a general medical

condition, substance; ex. delirium)

Hallucinations

• False sensory perceptions in the

absence of external stimuli

• In “primary” psychotic disorders (ex.

Schizophrenia), auditory hallucinations

are most common, followed by visual

• Hallucinations in other sensory

modalities are more suggestive of an

underlying medical cause or the effect

of an ingested substance

16

Hallucinations: Modalities in Summary

• Auditory

• Visual

• Tactile

• Olfactory

• Gustatory

Sensations of the unreal

• Derealization: A sense that the

outside world is unreal; dreamlike state

• Depersonalization: A sense that one

is disconnected from their physical

existence; as though observing oneself

from above or out of body

“Haven’t we Been Here Before?”

• Deja vu: Unrealistic familiarity with

novel situation or setting

• Jame vu: Sensation of novelty or

newness in a familiar situation or

setting
formation on how you would develop a rapport with your patient

History taking of psychiatry and psychiatric history?

• 
  Establish rapport as early as possible, determine patient’s chief complaint
  
• 
  Use chief complaint to develop a provisional differential diagnosis
  
• 
  Rule various diagnosis possible out by using focus detailed questions.
  
• 
  Follow up on vague or obscure replies with enough persistence to accurately determine answer to question.
  

• 
  Psychiatric history is the record of the patient’s life; it allows a psychiatrist to understand who the patient is, where they have come from and where the patient is likely to go in the future.
  
• 
  The patient is the patient’s own life story told the psychiatrist from the patient’s own mouth and his point of view.
  
• 
  The most important technique to allow the patient to tell their own story in their own word. In addition to gathering this information, a psychiatrist should strive to determine patient’s strength and weaknesses.
  

The patient history is outlined as follows:

• 
  Identifying data
  
• 
  Chief complaint and problem
  
• 
  Present illness (onset and precipitation factors)
  
• 
  Past illness (Psychiatric, medical, alcohol or other substance history)
  
• 
  Personal history (childhood, occupation, current living situation, marital status, religion etc)
  
• 
  Sexual history.
  

Rapport

• Establishing rapport is the first step of a

psychiatric interview, and interviewers

often use their own empathic responses

to facilitate the development of rapport.

Rapport: Checklist

• Yes No N/A

• 1. I put the patient at ease.

• 2. I recognized the patient's state of mind.

• 3. I addressed the patient's distress.

• 4. I helped the patient warm up.

• 5. I helped the patient overcome suspiciousness.

• 6. I curbed the patient's intrusiveness.

• 7. I stimulated the patient's verbal production.

• 8. I curbed the patient's rambling.

• 9. I understood the patient's suffering.

• 10. I expressed empathy for the patient's suffering.

• 11. I tuned in on the patient's affect.

• 12. I addressed the patient's affect.

• 13. I became aware of the patient's level of

insight.

• 14. I assumed the patient's view of the

disorder.

• 15. I had a clear perception of the overt and

the therapeutic goals of treatment.

• 16. I stated the overt goal of treatment to the

patient.

• 17. I communicated to the patient that I am

familiar with the illness.

• 18. My questions convinced the patient that I am

familiar with the symptoms of the disorder.

• 19. I let the patient know that he or she is not alone

with the illness.

• 20. I expressed my intent to help the patient.

• 21. The patient recognized my expertise.

• 22. The patient respected my authority.

• 23. The patient appeared fully cooperative.

• 24. I recognized the patient's attitude toward the

illness.

• 25. The patient viewed the illness with distance.

• 26. The patient presented as a sympathycraving

sufferer.

• 27. The patient presented as a very important

patient.

• 28. The patient competed with me for

authority.

• 29. The patient was submissive.

30. I adjusted my role to the patient's role.

• 31. The patient thanked me and made

another appointment.
dr. gall: growth and development:

focus on developmental milestones: very important: interpret the age of the pt depending on the mile stone and the age and the findings and development of milestones
Developmental milestones table 1.5 and 1.6
2-3 months - smiles, coos (response to human attention), lifts head

4-6 months – turns over, sits unassisted, grasps with hand, forms an attachment to primary caregiver and recognizes familiar people

7-11 months – crawls, stands, transfers toy from one hand to another (10 months), grasps with finger, peek a boo, waves bye bye, shows stranger anxiety, responds to name, imitates sounds

12-15 months – walks unassisted, shows separation anxiety, says first word, object permanence.

1.5yrs - says own name, uses about 10 words, moves away from and then returns to mother (reproachment), scribbles on paper, throws ball.

2 yr – shows negativity (favourite word is no), plays alongside but not with another child (2-4ys), names body parts and objects, feeds self with fork/ spoon.

3yrs – rides a tricycle, has sense of self as male or female.

4yrs - has imaginary companions, has nightmares, curious about sex differences

5yrs – draws a person in detail, romantic feelings about opposite sex parent.

6yrs - Ties shoe laces, rides two wheeled bicycle, understands finality of death, copies a triangle.
Developmental Milestones

• 
  Milestones are the history of a child from minute one to the present time; absence or delay signals potential abnormalities
  

• 
  Just as important is achieving a milestone, then losing it.
  

• 
  Areas of development: Physical, Motor, Language, Social, Cognitive
  

BIRTH

CHARACTERISTICS AND REFLEXES PRESENT AT BIRTH

CAPABILITIES OF INFANT PRESENT AT BIRTH

• 
  REACHING AND GRASPING BEHAVIOR
  
• 
  ABILITY TO IMITATE FACIAL EXPRESSION
  
• 
  ABILITY TO SYNCHRONIZE THEIR LIMB MOVEMENTS WITH THE SPEECH OF OTHERS
  
• 
  ATTACHMENT BEHAVIORS, SUCH AS CRYING AND CLINGING.
  

NEWBORN PREFERENCES

• 
  LARGE BRIGHT OBJECTS WITH LOT OF CONTRAST
  
• 
  MOVING OBJECTS
  
• 
  CURVES VERSES LINES
  
• 
  COMPLES VERSUS SIMPLE DESIGNS
  
• 
  PRFERENCE FOR FACIAL STIMULI
  
• 
  PREFERENCE FOR LANGUAGE STIMULI
  

INNATE REFLEXES

Blinking (Dazzle) Reflex

• 
  Disappears by 1 year
  
• 
  The eyelids close in response to bright light
  
• 
  Absence – might be blindness
  

Acoustic Blink
(Cohleopalpebral) Reflex

• 
  Disappears by 1 year old, but time is variable
  
• 
  Both eyes blink in response to a sharp loud nose.
  
• 
  Absence – might be hearing loss
  

Palmar Grasp Reflex

• 
  Disappears at 2 – 3 months
  
• 
  Place your fingers in babies hands
  
• 
  The baby flexes all his fingers around yours
  
• 
  Compare both hands
  
• 
  Presence beyond 4 months – cerebral dysfunction
  

Rooting/ Sucking Reflex: child’s head turns in direction of a stroke on the cheek when seeking a nipple to suck

• 
  Appears at 32 weeks
  
• 
  Disappears at 3 – 4 months
  
• 
  May be present longer during sleeping
  
• 
  Stroke the perioral skin
  
• 
  Baby will open the mouth and turn head on the side of stimulation
  
• 
  Absence – severe generalized or central nervous system disease
  

Trunk Irritation
(Galant’s) Reflex

• 
  Disappears at 2 months
  
• 
  Hold baby horizontally in one hand
  
• 
  Stimulate baby’s back by moving fingers along the paravertebral line from the shoulders to the buttocks.
  
• 
  Baby curves his back forward
  
• 
  Absent – transverse spinal cord lesions or injuries.
  

Placing/ Stepping Response

• 
  Disappears at 2 months
  
• 
  Hold the baby upright from behind
  
• 
  Allow the dorsal surface of the foot to touch the undersurface of the table
  
• 
  The baby flexes hip and knee, opposite foot steps forward. The baby makes few “steps”
  
• 
  Absence – paresis, babies from the breech delivery.
  

Rotation Test Reflex

• 
  Disappears at different time
  
• 
  Hold the baby under axillae
  
• 
  Turn him in one direction and then other
  
• 
  The head turns in the direction in which you turn the baby
  
• 
  If you restrain the head with your fingers, the baby’s eyes will turn in the direction in which you turned.
  
• 
  Abnormal – vestibular dysfunction.
  

Tonic Neck Reflex

• 
  Appears between birth and 2 months
  
• 
  Disappears at 6 months
  
• 
  The baby is supine
  
• 
  Turn the head on one side
  
• 
  The arm and leg on the side to which the head is turned extend, opposite side flexed
  
• 
  Persisting after 6 months old – cerebral damage
  

Tonic Neck Reflex



Crawl Reflex

• 
  The baby lies on his abdomen
  
• 
  Flex his knee and hips
  
• 
  Place your hand to his feet.
  
• 
  The baby pushes forward – “crawls”
  

Moro Reflex

• 
  Disappears at 4 months
  
• 
  Hold the baby and suddenly move your hands down
  
• 
  The arms abduct and extend with hands open and fingers extended, the legs flex. The arms return forward, the baby cries
  
• 
  Persistence after 4 months – neurologic disease
  
• 
  Asymmetric in arms – hemiparesis, brachial plexus injury, fracture
  
• 
  Absence of the leg response – low spinal injury, congenital dislocation of the hip
  

Babinski Reflex

• 
  Appears at 32 weeks gestation
  
• 
  Disappears within 1 year
  
• 
  Plantar response – dorsiflexion of the big toe, fanning of the other toes.
  
• 
  Persisting after 2 years of age – CNS lesion in the corticospinal tract
  

Tracking Reflex

• 
  Child visually follows a human face
  
• 
  Present at birth and continues
  

Physical Development

Gross Motor



Physical Development - Gross Motor

• 
  Newborn Reflex head turn, moves head side-to-side
  
• 
  1 month Lifts head when prone
  
• 
  2 months Lifts shoulders up when prone
  
• 
  3 months Lifts up on elbows, head steady when upright
  

Newborn



Physical Development

• 
  4 months Lifts up on hands, rolls from front to back, no head lag when pulled to sitting from supine position. Sits with support
  
• 
  5 months Rolls back to front
  
• 
  6 months Sits alone 30 seconds or more
  
• 
  7 months Sits well
  

Physical Development

• 
  8 months Pulls to a stand
  
• 
  9 months Crawls, fear of falling
  
• 
  10-11 months Cruises (walks holding on to furniture)
  
• 
  12 months Walks
  
• 
  15 months Walks backwards
  

Physical Development

• 
  18 months – 2 years Runs and kicks a ball, climbs stairs. Emergence of hand preference
  
• 
  3 years Walks up stairs alternating steps, rides a tricycle, stands on tiptoes. Bowel and bladder control training
  
• 
  4 years Walks down stairs alternating steps, hops on one foot.
  

Physical Development

• 
  5 years Skips, using feet alternately. Complete sphincter control
  
• 
  6 years Rides bicycle. Boys heavier than girls. Refines motor skills
  
• 
  12 + years Adolescent. Girls grow before boys. Onset of sexual maturity. Development of sexual characteristics
  

Social Development

Personal and Social



Social

• 
  Newborn endogenous smile
  
• 
  1 week knows mother’s smells
  
• 
  4 - 8 weeks Spontaneous social smile
  
• 
  4 - 6 months Discriminates social smile
  
• 
  6-12 months Stranger anxiety
  

• 
  Distress in the presence of unfamiliar face
  
• 
  First appears at 6months, peaks at 8 months and disappears by 12 months.
  

• 
  10 months ----Plays peek-a-boo
  
• 
  12 – 24 months Separation anxiety.
  

• 
  Distress of infant following separation from primary caregiver
  
• 
  Begins to disappears by 20-24 months
  
• 
  Failure to resolve separation anxiety result in school phobia.
  
• 
  Treatment focuses on child’s interaction with parents.
  

Social

• 
  ANACLITIC DEPRESSION:
  

• 
  CONTINUED ABSENCE FROM PRIMARY CAREGIVER BEYOND 6 MONTHS RESULT IN ANACLITIC DEPRESSION
  
• 
  SEEN EVEN WHEN PRIMARY CAREGIVER IS PHYSICALLY AND EMOTIONALLY UNRESPONSIVE AND DISTANT
  
• 
  CHILD BECOMES WITHDRAWN AND UNRESPONSIVE
  
• 
  DEPRESSED INFANT SHOW POOR FEEDING HABITS, POOR PHYSICAL GROWTH AND POOR HEALTH.
  

• 
  Play is solitary and exploratory (2 years)
  
• 
  15-18 months Dependency on parental figure. Caries or hugs a special toy.
  

Imitates some behavioral pattern with slight delay.

• 
  2 years “NO” is favorite word.
  

Onlooker and parallel play

Demonstrates love and protest

Social

• 
  3 years Gender identity. Sex-specific play groups. Understands taking turns.
  

Knows sex and full name

• 
  4 years Imitation of adult roles. Curiosity about sex (playing doctor). Nightmares, monsters. Imaginary friends. Associate or joint play (cooperative)
  

Social

• 
  5 years Peers are important. Romantic feelings
  
• 
  6-12 years Sports, team member. Separation of sexes, sexual feelings not apparent. Demonstration competence.
  
• 
  12 + years Adolescence Identity is critical issue. Cross-gender relationships
  

Motor Development

Fine Motor/ Adaptive
Motor

• 
  1 month Tracks horizontally to midline
  
• 
  2 months Tracks past midline, tracks vertically
  
• 
  4 months Reaches for bright objects, brings object to mouth
  
• 
  5 months Feet in the mouth
  
• 
  6 months Transfers object from one hand to the other
  

Motor

• 
  18 months Tower of 3 cubes. Scribes spontaneously and imitates writing
  
• 
  2 years Copies vertical and horizontal line, tower of 6 cubes. Pulls on a simple garment.
  
• 
  3 years Copies circle. Stacks 9 cubes. Cuts paper with scissors. Unbutton buttons. Puts on shoes. Feeds self well.
  

Motor

• 
  4 years Copies "+“. Grooms himself.
  
• 
  5 years Copies square, draws a recognizable man (3 parts). Dresses and undresses himself. Catches ball with 2 hands
  
• 
  6 years Copies triangle. Rides bicycle. Prints letters. Gains athletic skills. Improves coordination
  
• 
  7years Copies diamond
  

Language Development

Comprehension

Expression
Language

• 
  Newborn Alerts to bell
  
• 
  4 months Laughs aloud
  
• 
  6 months Has differential cries for hunger, pain, attention. Recognize warning, angry, and friendly voices. Responds to name. Babbling
  
• 
  8 months Repetitive responding. Listen to music or singing with interest
  

Language

• 
  10 months Mama/dada non-specific. Understands the word “no”. Looks at pictures being named for one minute. Listens for speech without being distracted by other sounds.
  
• 
  12 months Mama/dada specific, follows one step commands with gesture, 3-5 word vocabulary
  
• 
  18 months Understands basic body parts, simple objects. Understands up to 150 words.
  

Language

• 
  2 - 3 years Telegraphic sentences, 2 word sentences. 250 words vocabulary. Understands small body parts (elbow, chin), family name categories (grandma, baby). Understands size (one little, one big)
  

Understands functions (why do we eat, sleep)

• 
  3 years Complete sentences, 900 words vocabulary. Understands 4x that
  

Language

• 
  4 years Can tell stories, uses plurals, prepositions. Compound sentences. Understands analogies (bread is to eat, milk is to --- ). Can repeat a 12-syllable sentence correctly.
  
• 
  5 years Ask the meaning of the words. Is able to categorize items.
  
• 
  6-12 years Shift from egocentric to social speech. Vocabulary expands geometrically.
  

Tanner’s stage of development:: what stage has child reached: stage 1, 2 or 3: depending on findings of examination of extragenital: be able to differentiate the different stages

p.13t

TANNER STAGES OF SEXUAL DEVELOPMENT

Stage 1:

GENETALIA AND ASSOCIATED STRUCTURES ARE SAME AS CHILD HOOD, NIPPLES ARE SLIGHTLY ELEVATED IN GIRLS

Stage 2

SCANT, STRAIGHT PUBIC HAIRS, TESTES ENLARGE, SCROTUM DEVELOPS TEXTURE,SLIGHT ELEVATION OF BREAST TISSUE IN GIRLS

Stage 3

PUBIC HAIRS INCREASE OVER THE PUBIS AND BECOME CURLY, PENIS INCREASES IN LENGTH AND TESTES ENLARGE

Stage 4

PENIS INCREASES IN WIDTH, GLANS DEVELOP, SCROTAL SKIN DARKENS; AREOLA RISES ABOVE THE REST OF THE BREAST IN GIRLS

Stage 5

MALE AND FEMALE GENITALIA ARE LIKE ADULT, PUBIC HAIRS ARE NOW ALSO ON THE THIGHS , AREOLA IS NO LONGER ELEVATED ABOVE THE BREAST IN GIRLS
Learning theories and conditions:

Difference between operant and classical conditioning