The Emergence of Social Smiling in Infants

Wormann (2014) discusses the emergence of social smiling in infants, which is usually interpreted as the first positive expression directed towards a cause. This occurs when an infant with an initially expressionless face examines the face of another person, and their face and eyes light up while the corners of their mouth pull upward. The age of the first appearance of the social smile varies across cultures, ranging from the fifth to seventh week. Additionally, there are differences in its duration and frequency between the second and seventh month of life. Understanding these milestones is important for a basic understanding of normal child development.

Child Development Milestones:
4 weeks Responds to noise (either by crying, of quieting), follows an object moved in front of eyes
6 weeks Begins social smiling*
3 months Holds head steady on sitting
6 months Rolls from stomach to back, starts babbling
7 months Transfers objects from hand to hand, looks for dropped object
9 months Sits unsupported, begins to crawl
12 months Cruising (walking by holding furniture)
18 months Walks without assistance, speaks about 10-20 words
2 years Runs, climbs up and down stairs alone, makes 2-3 word sentences
3 years Dresses self except for buttons and laces, counts to 10, feeds themself well
4 years Hops on one foot, copies a cross
5 years Copies a triangle, skips

Hemiballismus is an uncommon condition that arises following a stroke affecting the basal ganglia, particularly the subthalamic nucleus. It is typically identified by uncontrolled flinging movements of the limbs, which can be forceful and have a broad range of motion. These movements are unpredictable and ongoing, and may affect either the proximal or distal muscles on one side of the body.

The Basal Ganglia: Functions and Disorders

The basal ganglia are a group of subcortical structures that play a crucial role in controlling movement and some cognitive processes. The components of the basal ganglia include the striatum (caudate, putamen, nucleus accumbens), subthalamic nucleus, globus pallidus, and substantia nigra (divided into pars compacta and pars reticulata). The putamen and globus pallidus are collectively referred to as the lenticular nucleus.

The basal ganglia are connected in a complex loop, with the cortex projecting to the striatum, the striatum to the internal segment of the globus pallidus, the internal segment of the globus pallidus to the thalamus, and the thalamus back to the cortex. This loop is responsible for regulating movement and cognitive processes.

However, problems with the basal ganglia can lead to several conditions. Huntington’s chorea is caused by degeneration of the caudate nucleus, while Wilson’s disease is characterized by copper deposition in the basal ganglia. Parkinson’s disease is associated with degeneration of the substantia nigra, and hemiballism results from damage to the subthalamic nucleus.

In summary, the basal ganglia are a crucial part of the brain that regulate movement and some cognitive processes. Disorders of the basal ganglia can lead to significant neurological conditions that affect movement and other functions.

Citalopram can moderately prolong QTc (>10 msec), while aripiprazole and paliperidone have no effect. Haloperidol and pimozide have a high effect, and quetiapine and amisulpride have a moderate effect. Clozapine, risperidone, and olanzapine have a low effect (<10 msec prolongation). Lamotrigine, mirtazapine, and SSRIs (excluding citalopram) do not have an effect on QTc interval.

The Thurstone scale’s reliability is limited due to the process of constructing it. While a large number of statements are collected and edited for clarity and relevance, the final form of the scale only includes items that have high interjudge agreement and fall at equal intervals. This selective process may result in a scale that is not entirely reliable.

The Camberwell Family Interview for Measuring Expressed Emotion

The Camberwell Family Interview is a tool designed to assess the level of expressed emotion within families. This interview was created with the aim of identifying the emotional climate within a family, particularly in relation to individuals with mental health issues. The interview is structured and standardized, with a set of questions that are asked to each family member separately. The questions are designed to elicit information about the family’s emotional atmosphere, including levels of criticism, hostility, and emotional over-involvement.

The Camberwell Family Interview is a valuable tool for mental health professionals, as it can help them to identify families that may be at risk of exacerbating mental health issues in their loved ones. By measuring expressed emotion, mental health professionals can gain insight into the family’s emotional dynamics and work with them to create a more supportive and positive environment. The interview can also be used to track changes in the family’s emotional climate over time, allowing mental health professionals to monitor progress and adjust treatment plans accordingly. Overall, the Camberwell Family Interview is an important tool for understanding and addressing the emotional needs of families affected by mental health issues.

Stevens-Johnson syndrome is a severe skin condition that can be caused by medication use of infection. Anticonvulsants, particularly lamotrigine, are often the cause. Symptoms include fever, sore throat, fatigue, and the appearance of ulcers and lesions in the mucous membranes. A rash of round lesions also appears on the face, trunk, arms, legs, and soles of the feet. It is a life-threatening condition that requires immediate medical attention.

Neurotransmitters are substances used by neurons to communicate with each other and with target tissues. They are synthesized and released from nerve endings into the synaptic cleft, where they bind to receptor proteins in the cellular membrane of the target tissue. Neurotransmitters can be classified into different types, including small molecules (such as acetylcholine, dopamine, norepinephrine, serotonin, and GABA) and large molecules (such as neuropeptides). They can also be classified as excitatory or inhibitory. Receptors can be ionotropic or metabotropic, and the effects of neurotransmitters can be fast of slow. Some important neurotransmitters include acetylcholine, dopamine, GABA, norepinephrine, and serotonin. Each neurotransmitter has a specific synthesis, breakdown, and receptor type. Understanding neurotransmitters is important for understanding the function of the nervous system and for developing treatments for neurological and psychiatric disorders.

Stigma Models

Stigma refers to any attribute, trait, of disorder that marks an individual as being unacceptably different from the normal people with whom they routinely interact, and that elicits some form of community sanction. The most popular model of stigma comes from the work of Link and Phelan, which has four aspects to it.

The first aspect is labelling, which refers to personal characteristics that mark individuals as different. These characteristics can be physical, mental, of social in nature and can include things like race, gender, sexual orientation, of mental illness.

The second aspect is stereotyping, which involves linking labelled characteristics to undesirable characteristics. For example, people with mental illness may be stereotyped as violent of unpredictable, even though the vast majority of them are not.

The third aspect is separating, which involves separating the labelled group and normal people by viewing them as very different. This can lead to social isolation and exclusion, which can further exacerbate the negative effects of stigma.

The fourth and final aspect is status loss and discrimination, which refers to the devaluing, rejecting, and excluding of the labelled group. This can take many forms, including employment discrimination, housing discrimination, and social exclusion.

Overall, the model of stigma developed by Link and Phelan provides a useful framework for understanding the complex and multifaceted nature of stigma and its effects on individuals and society as a whole.

Beauchamp (1993) argued that paternalism only applies to individuals who are capable of making decisions for themselves. In cases where an individual lacks autonomy, healthcare staff have a duty to make decisions on their behalf in their best interests. This includes preventing non-autonomous individuals from attempting suicide.

Deep autonomy provides further justification for paternalistic suicide prevention measures. While acknowledging an autonomous person’s right to take their own life, it could be argued that intervening in a suicide attempt allows the person to reflect and reconsider their decision.

The ‘cry for help’ model can also justify paternalistic interventions as individuals can be given help in finding happiness rather than resorting to suicide in a moment of hopelessness.

However, longer-term suicide prevention measures are generally criticized in the literature, especially in the case of autonomous individuals. Detaining an autonomous individual in a psychiatric hospital for an extended period solely to prevent suicide would be an unjustifiable abuse of civil liberty in the vast majority of cases.

The individual’s age, behavioral changes, disinhibition, and fatuous giggling suggest a diagnosis of frontal lobe dementia, which is further supported by their physical examination. The absence of focal abnormalities on EEG rules out the possibility of vascular dementia. Typically, EEG results are normal during the early stages of this condition and remain so until the advanced stages.

Individuals with histrionic personality disorder are commonly characterized as having superficial and unstable emotions.

Mental State Exam – Mood and Affect

Affect is a term used to describe a patient’s present emotional responsiveness, which is indicated by their facial expression and tone of voice. It can be described as being within normal range, constricted (where the affect is restricted in range and intensity), blunted (similar to constricted but a bit more so), of flat (where there are virtually no signs of affective expression). Mood, on the other hand, is a more prolonged prevailing state of disposition. A feeling is an active experience of somatic sensation of a passive subjective experience of an emotion, while an emotion is best thought of as a feeling and memory intertwined. Apathy is the absence of feeling. It is important to distinguish between affect and mood, as affect is momentary and mood is more prolonged.

Parenting Styles

In the 1960s, psychologist Diana Baumrind conducted a study on over 100 preschool-age children and identified four important dimensions of parenting: disciplinary strategies, warmth and nurturance, communication styles, and expectations of maturity and control. Based on these dimensions, she suggested that most parents fall into one of three parenting styles, with a fourth category added later by Maccoby and Martin.

Authoritarian parenting is characterized by strict rules and punishment for noncompliance, with little explanation given for the rules. These parents prioritize status and obedience over nurturing their children. This style tends to result in obedient and proficient children, but they may rank lower in happiness, social competence, and self-esteem.

Authoritative parents are similar to authoritarian parents, but they tend to be more responsive to their children. They set strict rules but provide explanations for them and nurture their children when they fail to meet expectations. The focus is on setting standards while also being supportive. This style tends to result in happy, capable, and successful children.

Permissive parents rarely discipline their children and avoid confrontation, allowing their children to self-regulate. They prefer to take on the role of a friend rather than a disciplinarian. This style often results in children who rank low in happiness and self-regulation, experience problems with authority, and perform poorly in school.

Uninvolved parenting is characterized by little involvement and few demands. This style ranks lowest across all life domains, with children lacking self-control, having low self-esteem, and being less competent than their peers.

Lewis’ Views on Mental Illness Diagnosis

Lewis believed that mental illness could be understood by examining the disturbance of part functions of the brain, such as emotion, perception, and memory, as well as a reduction in general efficiency. However, he cautioned against using socially deviant behavior as a means of diagnosis. Instead, he advocated for a multi-axial formulation approach, which was first proposed by Essen-Möller in 1947. Lewis also warned against relying on response to psychotropic medication as a reliable method of diagnosis. Overall, Lewis emphasized the importance of a comprehensive and nuanced approach to diagnosing mental illness.

Heuristics: Cognitive Shortcuts that can Lead to Diagnostic Errors

In the 1970s, Tversky and Kahneman proposed that humans use cognitive heuristics, of mental shortcuts, to simplify complex decision-making processes. However, these heuristics can also lead to systematic errors. One such heuristic is the representativeness bias, where individuals judge the likelihood of an event based on how closely it resembles a stereotype. For example, a person described as shy and detail-oriented may be more likely to be perceived as a librarian than a farmer.

Another heuristic is the availability bias, where individuals favor recent and readily available information over more accurate but less accessible information. This can lead to overestimating the frequency of certain events, such as violent crime. The anchoring-and-adjustment bias occurs when individuals lock onto salient features in a patient’s initial presentation and fail to adjust their impression in light of new information.

The framing effect is another bias where individuals react differently to a choice depending on how the information is presented. For example, a pharmaceutical company may present a drug as having a 95% cure rate, making it seem superior to a drug with a 2.5% failure rate. Base rate neglect occurs when individuals ignore underlying incident rates of population-based knowledge, leading to unnecessary testing of treatment.

Confirmation bias is a tendency to interpret information to fit preconceived diagnoses, rather than considering alternative explanations. The conjunction rule is the incorrect belief that the probability of multiple events being true is greater than a single event. Finally, diagnostic momentum occurs when clinicians continue a course of action initiated by previous clinicians without considering new information.

Overall, while heuristics can be useful in simplifying complex decision-making processes, they can also lead to diagnostic errors if not used appropriately. It is important for clinicians to be aware of these biases and actively work to avoid them in their practice.

Individuals from higher social classes are more likely to be diagnosed with bipolar affective disorder and eating disorders, while those from lower social classes are more commonly diagnosed with alcohol dependence, depression, schizophrenia, and substance misuse disorders.

Alcohol screening tools are available to assist in the diagnosis of alcohol problems. One such tool is the AUDIT (Alcohol Use Disorders Identification Test), which consists of 10 questions and covers harmful use, hazardous use, and dependence. Another tool is the FAST (Fast Alcohol Screening Test), which has just 4 questions and was developed for use in a busy medical setting. The CAGE is a well-known 4 question screening tool, but recent research has questioned its value. Other tools include SASQ (Single alcohol screening questionnaire), PAT (Paddington Alcohol Test), MAST (Michigan Alcoholism Screening Test), and RAPS4 (Rapid Alcohol Problem Screen 4). These tools can help identify hazardous of harmful alcohol consumption and alcohol dependence.

Disinhibitory Drug Reactions: Understanding Paradoxical Reactions to Benzodiazepines

Benzodiazepines are commonly prescribed for anxiety and sleep disorders, but they are also associated with paradoxical reactions, also known as disinhibitory reactions. These reactions are unexpected increases in aggressive behavior, sexual disinhibition, hyperactivity, vivid dreams, and hostility. However, the prevalence of these reactions is difficult to determine, as study findings vary widely from 1% to 58%.

Certain factors increase the risk of paradoxical reactions, including a history of aggression of poor impulse control, extremes of age (elderly of young), benzodiazepines with short half-lives, high doses of benzodiazepines, and intravenous administration of benzodiazepines. It is important to record these reactions, and if they are severe, it is advisable to avoid future use of benzodiazepines.

Prescribing in the Elderly: Iatrogenic Consequences

Many medications, both prescribed and over-the-counter, can have significant adverse effects in the elderly population. It is important to note that the lists provided below are not exhaustive, and only the most common and important examples are given.

Medications Linked to Delirium and Other Cognitive Disorders

Medications are the most common reversible cause of delirium and dementia in the elderly. Many medications can cause cognitive impairment, but the classes of drugs most strongly associated with the development of drug-induced dementia are opioids, benzodiazepines, and anticholinergics.

According to a systematic review done in 2011 (Clegg, 2011), long-acting benzodiazepines (e.g., diazepam) are more troublesome than those that are shorter-acting. Opioids are associated with an approximately 2-fold increased risk of delirium in medical and surgical patients (Clegg, 2011). Pethidine appears to have a higher risk of delirium compared with other members of the opioid class. This may be because pethidine can accumulate when renal function is impaired and is converted to a metabolite with anticholinergic properties.

Some antipsychotic drugs have considerable antimuscarinic (anticholinergic) activity (e.g., chlorpromazine and clozapine), which may cause of worsen delirium. Delirium is uncommon in newer antipsychotics (but has been reported).

Medications Linked to Mood Changes

The following medications are well known to precipitate mood changes:

– Centrally-acting antihypertensives (e.g., methyldopa, reserpine, and clonidine) can cause depressive symptoms.
– Interferon-a is capable of inducing depressive symptoms.
– Digoxin is capable of inducing depressive symptoms.
– Corticosteroids can cause depressive, manic, and mixed symptoms with of without psychosis.
– Antidepressants can precipitate mania.

Medications Linked to Psychosis

The following medications are well known to precipitate psychosis:

– Anti-Parkinson’s Medications (e.g., bromocriptine, amantadine, selegiline, anticholinergics (e.g., trihexyphenidyl, benztropine, benzhexol), and levodopa).
– Corticosteroids

Medications Linked to Anxiety

The following medications are well known to precipitate anxiety:

– Stimulants
– β adrenergic inhalers

Broca’s and Wernicke’s are two types of expressive dysphasia, which is characterized by difficulty producing speech despite intact comprehension. Dysarthria is a type of expressive dysphasia caused by damage to the speech production apparatus, while Broca’s aphasia is caused by damage to the area of the brain responsible for speech production, specifically Broca’s area located in Brodmann areas 44 and 45. On the other hand, Wernicke’s aphasia is a type of receptive of fluent aphasia caused by damage to the comprehension of speech, while the actual production of speech remains normal. Wernicke’s area is located in the posterior part of the superior temporal gyrus in the dominant hemisphere, within Brodmann area 22.

The US National Comorbidity study reports a 7.4% prevalence of social phobia within a year. Men have a lifetime prevalence of 4% for specific phobia, while women have a lifetime prevalence of 13%. Obsessive compulsive disorder has a one year prevalence of 2.1%. Men have a one year prevalence of 1.7% for agoraphobia without panic disorder. All diagnoses are based on DSM-IIIR criteria.

Sensory Distortions of Sound

Hyperacusis is a condition where an individual experiences an increased sensitivity to noise. This condition is commonly observed in people with anxiety and depressive disorders, as well as during a hangover of migraine. On the other hand, hypoacusis is a condition where an individual experiences a reduced sensitivity to sound. This condition is commonly observed in people with delirium and depression, where it is often accompanied by hyperacusis.

Typically, when a delusion arises, the patient feels a sense of relief from the preceding anxiety and tension. The delusional atmosphere is the perception that something is amiss, while the delusional mood refers to the accompanying feelings of anxiety and tension.

Waxy flexibility involves the examiner imposing postures on the patient, while posturing involves spontaneous postures. On the other hand, mitgehen is a type of automatic obedience where the examiner can easily move the patient’s body with a gentle touch, but unlike waxy flexibility, the body part quickly returns to its original position.

– Catatonia is a psychiatric syndrome characterized by disturbed motor functions, mood, and thought.
– Key behaviors associated with catatonia include stupor, posturing, waxy flexibility, negativism, automatic obedience, mitmachen, mitgehen, ambitendency, psychological pillow, forced grasping, obstruction, echopraxia, aversion, mannerisms, stereotypies, motor perseveration, echolalia, and logorrhoea.
– These behaviors are often tested in exam questions.
– Karl Ludwig Kahlbaum is credited with the original clinical description of catatonia.

It is not typical for 16 month old children to have already mastered the skill of combining words with meaning.

Linguistic Development and Risk Factors for Delayed Speech and Language

The development of language skills is an important aspect of a child’s growth. The prelinguistic period, from birth to 12 months, is marked by crying, babbling, and echolalia. From 6 to 12 months, a child responds to their name and can differentiate between angry and friendly tones. By 18 to 24 months, a child can use up to 40-50 words, mainly nouns, and starts to combine words in short phrases. By 36 to 48 months, a child has a vocabulary of 900-1000 words, can use plurals and past tense, and can handle three-word sentences easily.

However, there are risk factors associated with delayed speech and language development. These include a positive family history, male gender, twins, lower maternal education, childhood illness, being born late in the family order, young mother at birth, and low socioeconomic status. of these, a positive family history is considered the most reliable risk factor. It is important to monitor a child’s language development and seek professional help if there are concerns about delayed speech and language.

Antidepressants and Diabetes

Depression is a prevalent condition among patients with diabetes. It is crucial to select the appropriate antidepressant as some may have negative effects on weight and glucose levels. The first-line treatment for depression in diabetic patients is selective serotonin reuptake inhibitors (SSRIs), with fluoxetine having the most supporting data. Serotonin-norepinephrine reuptake inhibitors (SNRIs) are also likely to be safe, but there is less evidence to support their use. Tricyclic antidepressants (TCAs) and monoamine oxidase inhibitors (MAOIs) should be avoided. These recommendations are based on the Maudsley Guidelines 10th Edition.

Classical Conditioning: A Learning Theory by Ivan Pavlov

Classical conditioning is a learning theory developed by Ivan Pavlov. It suggests that events that occur together are associated and acquire a similar meaning. Unlike operant conditioning, which focuses on responses to behavior, classical conditioning looks at responses to stimuli. In classical conditioning, animals behave as if they have learned to associate a stimulus with a significant event. Pavlov demonstrated that innate responses, such as a dog salivating when it sees food, can be associated with a neutral stimulus, such as ringing a bell, so that ringing the bell can cause salivation even in the absence of food.

Important terms used in classical conditioning include stimulus generalization and discrimination, higher order conditioning, spontaneous recovery, and aversive conditioning. Extinction is the laboratory analogue of exposure therapy for anxiety disorders, while Counterconditioning involves pairing a feared conditioned stimulus with a positive outcome. Incubation occurs in fear responses, and reciprocal inhibition is a technique that aims to replace an undesired response with a desired one by counterconditioning. Some stimuli are more prone to conditioning than others, which is referred to as stimulus/biological preparedness.

History of Psychiatric Terms

In the exams, it is important to be familiar with the individuals associated with certain psychiatric terms. For example, Kraepelin is associated with dementia praecox and manic depression, while Bleuler is associated with schizophrenia. Other terms and their associated individuals include Hebephrenia (Hecker), Catatonia (Kahlbaum), Schizoaffective (Kasanin), Neurasthenia (Beard), Unipolar and bipolar (Kleist), Hypnosis (Braid), Group dynamics (Lewin), Group psychotherapy (Moreno), Psychopathic inferiority (Koch), Psychiatry (Reil), and Institutional Neurosis (Barton).

It should be noted that there is some debate over the origins of certain terms. While Kraepelin is often credited with coining the term dementia praecox, some sources suggest that it was first used in its Latin form by Arnold Pick in 1891. The original term demence precoce was first used by Morel in 1852. Despite this, the College appears to favor the Kraepelin attribution.

Primary Afferent Axons: Conveying Information about Touch and Pain

Primary afferent axons play a crucial role in conveying information about touch and pain from the surface of the body to the spinal cord and brain. These axons can be classified into four types based on their functions: A-alpha (proprioception), A-beta (touch), A-delta (pain and temperature), and C (pain, temperature, and itch). While all A axons are myelinated, C fibers are unmyelinated.

A-delta fibers are responsible for the sharp initial pain, while C fibers are responsible for the slow, dull, longer-lasting second pain. Understanding the different types of primary afferent axons and their functions is essential in diagnosing and treating various sensory disorders.

The symptoms listed are indicative of serotonin syndrome, which is a potential risk when prescribing two antidepressants. If left untreated, serotonin syndrome can lead to seizures and even death. Treatment typically involves supportive measures such as benzodiazepines and IV access, as well as serotonin receptor antagonists like cyproheptadine. Anticholinergic syndrome, on the other hand, presents with symptoms such as fever, dry skin and mucous membranes, mydriasis, and hyperthermia. Antidepressant discontinuation syndrome can cause a range of neurological, gastrointestinal, and affective symptoms. Idiopathic parkinsonism is characterized by tremors, rigidity, and bradykinesia, while neuroleptic malignant syndrome presents with symptoms such as hyperthermia, rigidity, confusion, tachycardia, and elevated CK and WCC levels.

Echolalia refers to the act of repeating someone else’s spoken words without any meaningful connection of context. This behavior is often observed in individuals with certain neurological of developmental disorders.

Formal Thought Disorders

In formal thought disorders, changes in the speed, coherence, and cogency of thought can be observed from a patient’s speech. These disorders can also be self-reported and may be accompanied by enhanced use of nonverbal language. One possible indication is a lack of an adequate connection between two consecutive thoughts, which is called ‘asyndesis’.

There are several types of formal thought disorders, including inhibited thinking, retarded thinking, circumstantial thinking, restricted thinking, perseverative thinking, rumination, pressured thinking, flight of ideas, tangential thinking, thought blocking, disruption of thought, incoherence/derailment, and neologisms.

Inhibited thinking is about the subjective experience of the patient, who may feel that their thinking process is slowed down of blocked by an inner wall of resistance. Retarded thinking, on the other hand, is about the observed quality of thought as inferred through speech, where the flow of thought processes is slowed down and sluggish.

Circumstantial thinking refers to an inability to separate the essential from the unessential during a conversation without rendering the conversation incoherent. Restricted thinking involves a limited range of thought content, fixation on one particular topic of a small number of topics only, and a stereotyped pattern of thinking.

Perseverative thinking is characterized by the persistent repetition of previously used words, phrases, of details to the point where they become meaningless in the context of the current stage of the interview. Rumination is the endless mental preoccupation with, of excessive concern over, mostly unpleasant thoughts.

Pressured thinking, also known as crowding of thought, is when the patient feels helplessly exposed to the pressures of floods of different ideas of thoughts. Flight of ideas involves an increasing multitude of thoughts and ideas which are no longer firmly guided by clear goal-directed thinking.

Tangential thinking occurs when the patient appears to understand the contents of the questions addressed to them but provides answers which are completely out of context. Thought blocking of disruption of thought refers to sudden disruption of an otherwise normal flow of thought of speech for no obvious reason.

Incoherence of derailment is when the interviewer is unable to establish sensible connections between the patient’s thinking and verbal output, which is sometimes also called derailment. Neologisms involve the formation of new words of usage of words which disregard normal conventions and are generally not easily understandable.