**************************************
Click here to view the embedded video.

Ever feel lost in the Pre-Med grind, not knowing what to do next?

Have specific questions about the medical education process and get mixed answers all over the web that leave you feeling more confused and alone?

Chances are one of the hundreds of people I’ve coached since 2004 have asked me the same questions!

This podcast explores my new website’s organization. It will be released soon, don’t worry - and you can join for only $12 ! (UPDATE: it’s released here –> Medical Support Community).

I took all of the how-to video tutorials, email questions and survey responses and organized them all into the 15 Sections below.

The only way to access this information is on the new site: http://medical-mastermind-community.com/podcast/speed-reading-for-medical-school

1 Getting Started

ARTICLES:
•    Overview of the medical education process
•    16 Step PreMed Guide
•    Daniel Williams’ story
•    Importance of journaling
•    SAMPLE interview journal
AUDIO:
•    The medical education process
•    What med school is really like

2 Premedical Decision Making

ARTICLES:
•    Admission requirements
•    Canadian med student career choices
•    Deciding on a career in medicine
•    ECFMG certification fact sheet
•    ECFMG information booklet
•    Four reasons to avoid medical school
•    Med school affects undergrad choices
•    Seven osteopathic competencies
•    UK med student career choices
•    US med student career choices
AUDIO:
•    Admission rates
•    Admission requirements
•    Deciding on a career in medicine
•    Four reasons to avoid medical school
•    Osteopathic medical training

3 Organizing Your Experiences

ARTICLES:
•    Address label templates
•    Checklist for getting organized
•    Email accounts
•    Legal documents
•    Master application binder
•    References
•    Transcript checklist
•    Transcript request template
•    Work history template

4 Building Character Into Physician Training

ARTICLES:
•    Arrogant doctors hurt patients
•    I DON’T KNOW – The three most important words in medical education
•    Six habits of highly respectful physicians
•    Words as scalpels
•    Ethics
•    Euthenasia
•    Human subjects research training
•    Medical futility
•    Neurenberg
•    Suicide
•    Ethics Movement
•    Tarasoff case
VIDEO:
•    Becoming the genuine article

5 Components of the Application

ARTICLES:
•    Academic honors
•    SAMPLE Application summary sheet
•    Certifications
•    Extracurricular activities
•    Letters of recommendation
•    Composing a letter of recommendation that captures the applicant as an individual
•    Dr Williams’ medical school application
•    Military experience
•    Research
•    Research commentary
•    Student organizations
•    Volunteer activities
AUDIO:
•    Letters of recommendation

6 Writing Your Memorable Application

ARTICLES:
•    Checklist for the personal essay
•    How to write personal essays
•    SAMPLE personal essay
•    Practice vision essay
•    SAMPLE research description
•    SAMPLE MD PhD interest letter
•    SAMPLE Secondary application questions
VIDEO:
•    Packaging your story
•    Essay tips

7 Choosing Your Top Medical Schools

ARTICLES:
•    100 years after the Flexner report
•    Admissions – insider report
•    Allopathic medical school – US and Canada
•    Caribbean medical schools
•    Feedback in clinical medical education
•    Hot topics in medical education
•    Impact of formal continuing medical education
•    Learner-centered approaches in medical education
•    Osteopathic medical schools
•    Systematic review of physician performance
•    Teaching evidence based medicine
AUDIO:
•    Osteopathic physicians – are they different?

8 Counting the Costs

ARTICLES:
•    Financial assistance checklist
•    Debt is not all created equal
•    Financial assistance
AUDIO:
•    Burnout interview question
•    Financial aid in medical school

9 Grades

ARTICLES:
•    AMCAS’ GPA calculation
•    GPA calculator
•    The perfect GPA
AUDIO:
•    The perfect GPA

10 Sizing up the Competition

ARTICLES:
•    50 listener questions – the power of exploiting your competition
•    Checklist for exploiting your competition
AUDIO:
•    50 frequently asked questions
VIDEO:
•    Survival strategies

11 How to Study

ARTICLES:
•    MCAT study method
•    MCAT – special report
•    Checklist for maximizing your study methodology
VIDEO:
•    Exam strategies Part A
•    Exam strategies Part B
•    Speed reading system
•    5 Step study method
AUDIO:
•    5 Step study method

12 Personalized Progress Feedback

VIDEO:
•    Custom progress feedback

13 After Your Medical School Application

ARTICLES:
•    Having a successful interview
•    Interview topics
•    SAMPLE UT Houston interview letter
•    Program results by specialty
VIDEO:
•    Residency considerations
•    Insider match application and ranking system
AUDIO:
•    Changes in the match system

14 Maintaining Your Edge

VIDEO:
•    Foxmarks Bookmarks tool for organization
•    iGoogle tutorial
•    Time management

15 Study Materials

MEDICAL SCHOOL:
•    Modern Medical Scrolls – 1275 pages of medical student notes
VIDEO:
•    Study Notes Video
Medical College Admissions Test:
•    14 Biochemistry documents
•    1 Evolutionary document
•    15 General Chemistry documents
•    8 Pathophysiology documents
•    4 Physics documents
United States Medical Licensing Examination
•    Bonus USMLE document

Reference:
Must have a free account with Academic Medicine, the journal of the AAMC, to view: http://journals.lww.com/academicmedicine/Fulltext/2001/10000/America_s_Best_Medical_Schools__A_Critique_of_the.5.aspx

SEE THE FULL REPORT HERE: Evolution of a Physician In Training: Effects of the medical education pipeline on personal and professional development.

Daniel M. Williams, MD

The 5 phases of a physician in training are general categories that describe the professional and psychological changes that students can expect to face. These have been organized into a Medical School Mindmap full of 179 peer-reviewed, scientific articles that describe the processes necessary to become the consumate physician.
The Phases are as follows:

1. Standing At The Precipice: The Premed Syndrome
2. Adaptation
3. Assimilation
4. The Let-Down
5. Reemergence

This area of research is meant to provide the foundation for a Health and Wellness Initiative among physicians. Physician Health is a top priority with Dr. Daniel Williams and each area is broken down inside the Medical Mastermind Community that has grown up around this ideal.

Here is an excerpt from the original draft:

Phase 1: Standing at the Precipice

Premedical students engaged in the early medical education pipeline frequently share similar goals and ambitions. The most commonly described premedical student traits are hard working, competitive, motivated, goal-oriented, altruism, and prestige-seeking (22-24). Fairly early in their premedical experience they begin to learn of the imperfection in the system.

A number of frustrations faced by these bright, enthusiastic students begin before even entering medical school. The challenges face by these future physicians can be categorized as follows:

1. Selection Bias. Learning that affirmative action exists without understanding the need for diversity can be a shock (143,145,156).
2. Academic Preparation. Realizing their undergraduate premedical and M.C.A.T. preparation may not actually predict how competent they will be as physicians can be disheartening (46,45,48).
3. Premedical Advising. Many students encounter premedical advisers, though wonderful guidance has been published for decades (11,15,17).
4. Admissions Criteria. The paradigm shift being birthed in premedical curriculum, which seeks to broaden one’s humanities background and foster empathetic relationships, is taking a surprisingly long time (4,6,27,28,30,31). The transition period as more medical schools are changing their admissions criteria and interview process can leave the premedical student confused about what is important in their preparation (184).

Because these sytstem-wide messages that contradict their altruistic nature, it is not surprising that the majority of students matriculating into medical school already have a well established ethical framework that is difficult to mold (26).

Further, two of the most historically trusted sources of information flat fail the premedical student attempting to learn about medical education. First, institutions of higher learning remain hyper-focused on grade point average though is associated with mere surface learning in medical school and the “MCAT Myth” of requisite rote memorization had been debunked by the mathematical application of Bloom’s Taxonomy (46). Second, nationally syndicated journalists yield influence in the ranking of “top medical schools”, but their method are ill-conceived; are unscientific; are conducted poorly; ignore the value of school accreditation; judge medical school quality from a narrow, elitist perspective; do not consider social and professional outcomes in program quality calculations; and fail to meet basic standards of journalistic ethics (32).

Sadly, the more idealistic and altruistic the nature of the unsuspecting premedical student, the greater the expectations in their career, and the greater the disappointment that comes in later phases in their evolution.

If we can be of any specific help to you, please feel free to contact us through the Ask A Doctor page.

Ping my blog

Because no two people read the same MCAT passage exactly the same, it’s important to harness your internal dialogue to interpret passages, stay calm, and score higher - all at the same time. To learn more, visit www.testprepny.com.

There are only a few more episodes of expert interviews that will appear on this site. The continuation will be on www.Medical-Mastermind-Community.com

To get more Test Anxiety training and management instruction, join the CD of the Month Club, which also included Medical Mastermind Teleconferences with Doctor Dan.

Enjoy,

Dr. Dan

Dr. Ferdinand’s tells us about his not-so-secret performance on the MCAT and about his fatal error during planning his MCAT that caused him to not be able to even take the exam!

Listen to ALL of the expert interviews on the Medical School Podcast.

[More...]

The Association of American Medical Colleges administers the MCAT, accredits allopathic medical schools in the U.S., and manages the medical school application service.

The trend over the past 2 decades has been to emphasize thinking, organizing information, and problem solving rather than rote memorization.

In this episode, we two physicians discuss exactly why that is, what you can do to prepare, and ultimately whom you can trust when it comes to such an important exam – yourself!

Future episodes will cover

* Dr. Ferdinand’s 6 Steps to MCAT Preparation, which is remarkably similar to my 5-Step study method.

* Dr. Ferdinant’s interview with the “Father of MCAT Books” (Dr. Flowers)

* How a mastermind community can help premeds AND medical students

Listen in to learn more…

In this interview with Randy Freeman, a Premedical University DVD Home Study Course graduate, we delve into 4 major areas:

1. How to get the “I’m GOING TO be a doctor” mentality
2. Levels of Pre-Med sophistication and commitment
3. Can you change your priorities later down the road, as a physician?
4. Premedical Solutions that work - study for the MCAT while in undergrad!

The American Medical Student Association will again promote my next live, 2-day conference on July 18-19, 2009. Several things will happen at this Medical School LIFE Conference:

• The new Medical Mastermind Community site is now launched and explained in this podcast!
• 102,000+ Medical Students and Pre-Med Students are invited to watch the conference via live-streaming or phone in

Finally 3 major topics will be covered at this Burnout Prevention seminar:

1. How To Survive And Thrive In Medical School
2. Advanced Pre-Med Seminar
3. Single Payer Solution For Health Care Reform.

Registration includes the Pre-Med DVD Home Study course and residency/med school application homework is required prior to the conference date in order to maximize you individualized coaching sessions.

This conference is sure to be hoot!

Thanks for your support,

Doctor Dan

*******************************************************

Announcements: * CD of the Month Club is now in it’s 21st month. The infrastructure for mass production is now in place.

Check out the new MCAT podcast interviews with GOLD STANDARD MCAT author, Dr. Brett Ferdinand

The Medical Mastermind Community is now live! Call me on our next pre-med conference call!

*******************************************************

A future doctor recently told me she made a 16% on a full-length Kaplan Practice MCAT. While that sounds bad, let’s put that score into perspective and look at how overall core knowledge deepens - specifically, how that is reflected in practice test scores. We’ll also delve into how to predict what score you’ll make on the actual MCAT.

This was my answer: “I sincerely understand your frustration and experienced it myself after taking the Kaplan course and my grades averaged out to be the same, having taken the MCAT 3 times. As a premed adviser now, I get this question a lot. You are not alone.” You have a multi-part topic, so let me take each item in turn: 1. What do people actually make on the MCAT? What is the MCAT cut-off?

Please give me real numbers! It’s on a bell curve so if you’ve taken statistics you know that they can separate out the elite by keeping people away from the 100% correct end of the spectrum. In fact, 60% raw correct answers can actually be solid and each test is weighted differently. See, each test is drawn from a bank and each question is weighted for it’s own usefulness.

There are a significant amount of test questions that are being assessed as keepers, but are not part of your grading. Here is where you can find the most recent REAL MD MCAT scores in Texas, Osteopathic MCAT Scores, and AMCAS MCAT Scores.

2. Do practice MCAT tests commonly show low scores? [Better yet, do these low practice scores really reflect how well I'll do on the real MCAT?] ANSWER: A full-length practice MCAT form a reputable source, such as Kaplan, AAMC, or Princeton review are reasonable reflections of how well you’ll do on the real thing. How to interpret your performance on these tests is actually more useful in real life. As a rule of thumb, scoring between 60-70% is actually average and approaching a solid score. Let me be clear, I’m not talking about little quizzes because the sample size of questions does not give you an accurate representation of your body of knowledge. Only pay attention to full-length, timed tests. I recommend you do between 3-7 of them, until you consistently get your overall average over 60% correct. If you expect to ace the MCAT you’ll want closer to an 80% average.

3. Is there another way to prepare for the MCAT? ANSWER: The best way I teach people to prepare for the MCAT is to start learning the material from the first day in undergraduate, if possible. Buy a respected review book and take notes in it while in undergrad and taking those classes. Write down revelations and pearls of wisdom as you begin to get insight into the different prerequisite disciplines - keep the book near you and review it periodically. Too many people only “review” for the MCAT, which often means RELEARNING material form 1.5 years ago or more and this is a tremendous waste of brainpower, not to mention the added stress has been shown to decrease long-term memory (cited resource is a meta-analysis). *******************************************************

Residency Spotlight: Surgery After 4 years of medical school, General Surgery takes 5 years. Many people sub-specialize after that and go to fellowships. Fellowships may be in GI Surgery, Pediatric Surgery, Trauma, or transplant. There are some training programs that are surgical which do not require a General Surgery residency first: Urology, Ob/Gyn, and Neurosurgery. Cheers, Doctor Dan

Hi!

I hope you enjoy the fact that I’m switching to video. You can still just listen on your iPod if you prefer, but I’ll be showing you tons of on-screen tutorials. You can see the video version by looking in the Video Podcasts section of your iPod directory (scroll through the videos…).

The MCAT questions, DVD course and FREE E-book are now available through the Medical Mastermind Community only. Ive launched a community website for all the fans that have built up around this movement in the past 2 years!

Cheers,

Dr Dan

• All 200 of the peer-reviewed, scientific journal articles were posted inside the web site for members only. They outline every facet of the medical education journey and correspond to the 5 Phases in the Evolution of a Physician in Training, which is my Physician Wellness Initiative. The idea is to increase awareness, receive validation, and try suggestions from others to find relief. So, just read the articles as you face the different ups and downs along the way.

• All of the medical school exams were also uploaded to the website. Previously they were only available as part of the CD of the Month Club, but we found it was inconvenient not knowing which tests covered specific material. The web outline breaks down each block exam by the topics covered on each set of tests. You can check out the navigation without logging in.

• Facebook 30-day challenge. If you’ll make a video about the Medical School Podcast or Speed Reading for Medical School course, I’ll give you a free, 30-day account tot he Medical Mastermind Community online - a $27.99 value. This includes our biweekly conference calls, from which video archives are now all updated.

Call me, Doctor Dan, in one of our Medical Mastermind Support Groups and discover how to stay true to yourself during rigors of the medical education marathon.

Check the Medical Mastermind Group Schedule and login information. Hope to talk to you on the next call.

The “medical education process” covers the whole gamut from thinking about becoming a doctor, through the prerequisites, MCAT, and application, and never really ends in residency, fellowship and with continuing medical education as a practicing physician.

Do you have what it takes to be a lifelong learner?

Better yet, how many people really encourage you to follow that dream? My guess is that you’re like the hundreds of students I have coached, and that you’ve had some degree of discouragement along the way.

While there are many reasons for this, the only thing that matters to the motivated pre-med and medical student is getting through it - sanely!

Well, that my friend is exactly what the Medical Mastermind Community is all about. This video describes a hint of what the upcoming community is all about. If you want to learn more, sign up at MedicalMastery.com on the Early Notification List and be included.

In the meantime, seek out existing pre-med clubs, medical student organizations, Healer’s Art courses or hospital volunteer offices for support. If someone brings you down, stresses you out, or discourages you from accomplishing your dreams - get away from them!

Yes, this may mean friends and family. They’ll come around later when you’re successful, believe me. You need new friends. Just like the saying “you are what you eat”, you think like those with which you spend your time.

Hope this was an encouragement and sparks some self-care interest. The medical education process is a substantial percentage of your adult life - don’t forget to live!

Doctor Dan

====================================================

The medical school application is only one phase of your life. In this podcast and blog, I put this event in to the context of the entire medical school application process, give you some things to look forward to and prepare for, as well as direct you to where you can find an entire archive of tips like these all in one place.

By the time you submit your medical school application, you deserve a pat on the back. After all, you’ve completed the MCAT (in most cases), most of the medical school prerequisites and college, and overcome a large part of the mind game - talking yourself out of it. Many people change their mind and a growing trend is for ill informed pre-health advisers, with no qualification to speak on the subject, to discourage attending medical school.

From the time you submit your medical school application to the time you start your first day of medical school, there are a lot of activities that take place.

Interviews, ranking programs for the electronic match, match day, welcome parties, moving, and shopping. Oh yea, and preparing those closest to you that you’re about the be besieged by books and to prepare for some distance. Let’s take each of these in turn…

Getting an interview is often the hardest part to getting into medical school. More specifically, getting an adequate number of interviews. How many medical school interviews is enough? Most people feel ten is a good number. Why so many? Because they interview 7-10 times more students than they have seats for.

After you complete all of your interviews, you log in to the online ranking and matching service and rank the programs in order of your preference (only the ones you interviewed at). If there’s a school you don’t want to go to under any circumstances, you don’t have to rank it in your list even if you interviewed there. An important step is to “certify your rank order list”. You can rearrange the list as you decide for weeks, but once you certify it there’s no turning back. (I certified mine the day before.) If you don’t certify you’re not in the match, so don’t wait too long.

I made a video tutorial on the match application and ranking system. It’s the only behind-the-scenes look available and I’ll tell you how to get your hands on it at the end of this podcast.

In November of 2008, I released Episode 9 and we discussed drastic changes in the match system, primarily those in the Texas system. You can visit that episode in iTunes or MedicalMastery.com.

Match day will be memorable no matter what happens. At a certain day and time, usually around February or March, thousands log in to the online ranking service to find out if they’ve matched and where.

The match also occurs in the 4th year of med school and is very similar, but I thought I’d discuss the differences here.

This is really similar to a 3-day process, so let’s take the events in order:

Day 1: Login to see if you matched or not. It tells you YES or NO, not where you matched.

Day 2: Those that didn’t match are able to view a list of all programs that have unfilled residency positions. Your medical school usually helps you find a program somewhere during a 48 hour period known as

the scramble.

Day 3: Two days later you meet at your school and usually have some sort of ceremony to find out where you matched.

Included in my archives are a Video on residency considerations and an article on program results by specialty.

Many medical schools have some sort of Welcome Weekend, or event before medical school that allows you to meet people, loosen up, and get psyched for medical school. In my school we did this the weekend right before it started. This is a very fun time and where you’ll meet many lifelong friends.

====================================================
Big Question: What is your medical school entrance party or interview story?  Comment below…
====================================================
QUICK TIP: All of the videos, interviews, and articles will soon be released to the public. Sign up for the early notification list at www.PremedicalUniversity.com. You’ll also get the 7-day PreMed email course when you sign up for free. You can unsubscribe any time.
QUICK REFERENCE:
American Medical College Application Service: http://www.aamc.org/students/amcas/start.htm
====================================================

Mission Statement
“Medical Mastery seeks to podcast meaning into medical education by combining faith, high-quality lectures, and charity.”

Announcements:
Dropping a hint about my big project…got a high speed internet connection?

Also, for simplicity all CD’s will be mailed out during the last week of the month.

====================================================

Podcast topic

“If you had it to do all over again, what would you do different?”

This is a question I get a lot, in different forms. In fact my new big project I’m coming out with in the next few months is exactly geared toward answering this question - in all it’s detail.

See, feedback from my podcasting has made me realize that my experience with the premed obstacles you face is fodder for you cannon! I get just as excited with you as I coach students and reawaken their dreams of becoming a physician.

The biggest tips I can think of to answer this question with brevity are the following:

1. As an undergrad, write out what my life’s priorities are. Establish from the beginning and keep the document handy for editing as time passes.

2. Identify what you are and are NOT willing to sacrifice in persuit of your goals. The “I’ll do anything” mentality won’t be reliable forever.

3. The first year of medical school and then test weeks will clearly have to be priority during medical school. It’s four years, but many students schedule easier months during the last year.

4. Much further down the road, do the same thing when considering which residency specialty interests you. Many people change their minds about this over time so stay flexible as you learn new information.

5. Keep your “Life Priorities List” handy as you investigate your career options. Note: you really don’t have to do this until the end of the third year of medical school, when you schedule your electives for the fourth year.

Biggest tips for residency:

1. Choose something you are passionate about.

2. If possible, don’t make any BIG life changes. Of course, who can really plan these things? There’s never a “perfect” time to have a family..

3. Outline reservations you’ll have - that is, things you WON’T compromise clearly identified at the outset. As you progress through residency, which can be all-consuming, an indicator that you may need a career change is when you find yourself compromising your life’s priorities.

====================================================

QUICK TIP: Sign up for the next Live Premed Advising Webinar when you enroll for the 7-day email course. Limited number of people available for the Tele-Clinic and I may offer this to you for a short while.

QUICK REFERENCE: http://premedicaluniversity.com

====================================================

Charity of the Month for March 2009: Habitat for Humanity will receive all donations made in the upper left hand corner of www.MedicalMastery.com.

Charity Mission Statement: Decent Housing For All

“Through the work of Habitat, thousands of low-income families have found new hope in the form of affordable housing. Churches, community groups and others have joined together to successfully tackle a significant social problem – decent housing for all.

Today, Habitat for Humanity has built more than 300,000 houses, sheltering more than 1.5 million people in more than 3,000 communities worldwide.”

“Since its founding in 1976 by Millard and Linda Fuller, Habitat for Humanity International has built and rehabilitated more than 300,000 houses with partner families, helping house more than 1.5 million people and becoming a true world leader in addressing the issues of poverty housing.”

====================================================

Mission Statement:
“Medical Mastery seeks to podcast meaning into medical education by combining faith, high-quality lectures, and charity.”

Episode 12: Ostopathic Medicine Training: What’s so special about it?

====================================================

There is more than one way to become a physician: Allopathic and Osteopathic. Today’s discussion is about the pathway to doctor of osteopathic medicine (D.O.)

In addition to all of the traditional aspects of physician work that you’re familiar with, osteopathic physicians theoretically have a few other tenants that they emphasize:

1. The human body systems need to be in correct relationship with one another (really just normal physiology)

2. The musculoskeletal system gets some special attention.

I’d like to add a third: the osteopathic physician is taught to take care of the “whole patient”. Holistic medicine refers to the taking care of the whole person, i.e., mental, physical, emotional, and spiritual health.

Really the only difference is that they can pop your back! They get all the same jobs, direct hospital departments, and go to all the same residency programs.

So, why are we talking about them? Because some people don’t apply to these programs as a first choice, leaving opportunities on the table for you.

In 2007, the average allopathic applicant had a MCAT score of 28 and a GPA of 3.5. An average osteopathic applicant had a MCAT of 25 and a GPA of 3.5.

Many residency programs accept the COMLEX exam, but some may also require the USMLE.

====================================================
MEDICAL SPECIALTY SPOTLIGHT: Infectious Disease

4 years of medical school
3 years of internal medicine residency
2-3 years of fellowship training in Infectious Disease

Traditionally, Infectious Disease specialists operate as a consult service in the hospital. The main activity is in clinics.

The approach is not that the ID doctor is there when someone has an infection, but they are there to help when the treating physician confronts a complicated patient outside his or her expertise.

They also hold the purse strings for the hospital’s pharmacy by serving on committees that decide which drugs can be dispensed and which ones the hospital will and will not provide. The newer, expensive antibiotics often need special approval from the committee on an individual basis. They’re not being mean, their slowing down the evolutionary resistance mechanisms of the microorganisms trying to kill our patients.

====================================================

QUICK TIP:

Apply to them first so that you don’t forget to do it. Remember, there is nothing second rate about being a D.O.

QUICK REFERENCE:

National Board of Osteopathic Medical Examiners

http://www.nbome.org/

List of Osteopathic Medical Colleges:

http://www.nbome.org/colleges-list.asp

====================================================

Announcements:
Happy New Year!
It’s now been 9 months of podcasting and we have over 21,178 downloads. I’m very encouraged by your emails and support.

In that short amount of time, hundreds of your questions have been answered and organized into a mindmap. With your help we put together a comprehensive, individualized PreMed coaching program. Visit www.PremedicalUniversity.com for more information.

The PreMed CD of the month club now has a link on the right of MedicalMastery. There is room for 11 more people right now. First come, first serve. That link will only be available intermittently when seats are available.

Live Teleclinics now available. Sign up for the free PreMed eBook on MedicalMastery.com and you’ll also get email notification of upcoming teleclinics.

Submit topics in the online survey “Grill the Guru”. The Ebooks is 16 chapters emailed to you weekly with other, exclusive PreMed strategies and insider

advice also. In total, you’ll get over 3 months of PreMed email content that you can save, store, and search in your email service for years to come!

DON’T DELETE the emails.

====================================================
Podcast topic

The first teleclinic we did had a nice video slide that covered all the steps in the medical education process. The new website that will host the free teleclinics.

After you’ve mapped out when you’ll be finished with college and all of the prerequisites for medical school, the next available August would be your first potential entering month and year. Plan to take the Medical College Admissions Test the year before.

You can successfully back-schedule from this date all of the necessary preparations so that you have time to do everything you need.

The first year of medical school is perhaps the hardest of all. You will be forced to adopt different learning styles for different types of information on the fly. The focus is on how the body works normally.

FIRST YEAR CLASSES:
Biochemistry
Cell development and tissue biology
Community health
Epidemiology / biostatistics
Family medicine
Gross anatomy
Growth and development
Health care policy
Hematology
Histology
History of medicine
Immunology
Interviewing
Introduction to clinical skills
Medical ethics
Molecular biology
Physiology
Preclinical electives
Problem-based learning

The second year is when you learn what goes wrong with human physiology.

SECOND YEAR CLASSES:
Addiction medicine
General pathology

Infectious disease
Introduction to clinical medicine
Microbiology
Psychopathology
Psychiatry
Nutrition
Neuroscience
Pathophysiology
Pharmacology
Preclinical electives
Problem-based learning
Systemic pathology

At the end of the second year, you take the United States Medical Licensing Exam, Step 1. This is the weightiest of the 4 USMLE exams as it affects which residency specialty you get into.

The third year starts 2 years of clinical rotations. Often one month long, you spend time doing many of the specialties.

THIRD YEAR ROTATIONS:
Surgery
Internal medicine
Pediatrics
Obstetrics and gynecology
Psychiatry
Primary Care

The USMLE Step 2 Clinical Knowledge is taken before the end of medical school, as well as Step 3 Clinical Skills. The former is a computerized exam, the latter is an in-person, all day patient care simulation.

The fourth year is the most relaxed of all. By this time, you already have the letters of recommendations you need for residency application and the 4th year elective grades don’t matter as much as the USMLE Step 1 and basic science years’ grades. Application for residency begins this year so some people have trouble choosing a specialty at this point because there isn’t much time between 3rd year and application time.

Internship is the same thing as the first year as residency. Depending on the residency tract, some people do take a separate intern or transitional year and then begin their second year of postdoctoral training.

After the first year of residency training, you are eligible to take the USMLE Step 3 - the last of them! My, what a good feeling it is to be done with them!!

The major goal comes after residency when you take your board specialization exam.

Fill out the Grill the Guru survey on medicalmastery.com to let me know if you are interested in a Medical Specialty Spotlight as an addition to future podcasts. I need 30 responses to proceed with that decision.

====================================================

QUICK TIP:

Map out the rest of your college classes needed for both graduation and medical school prerequisites. Use a physical calendar, printed out for the next couple of years if needed. Write on it by semester, journal on it, and check off your classes as you complete them.

This will help you even if you already know it by heart.

Be sure you have a signed degree plan by your department chair so there are no surprises when you’re ready to graduate.

====================================================

QUICK REFERENCE: CDC Internship Opportunities

http://cdc.gov/education/

Click on the College Student links for more information.

AMSA PreMed: Definitely check out the listserve option. You must be a member, though. Membership starts at $35.

http://amsa.org/premed/

====================================================

Charity of the Month for January 2009: Innerchange Freedom Initiative http://www.ifiprison.org/

The InnerChange Freedom Initiative (IFI) is a proven, voluntary and holistic values-based Reentry Program. It seeks the development of the whole person – spiritually, intellectually, emotionally, and physically. The spiritual formation aspect of the program is based on the life and teaching of Jesus Christ.

Charity Mission Statement:
This mission of IFI is to create and maintain an environment where change may take place and to foster respect for law and the rights of others.

Testimonial

“I had the chance to be mentored by people who really cared about me—Christian men who are a good example of how to treat their family and loved ones,” he describes. “I now have a desire to put other people first.”

====================================================

Mission Statement
“Medical Mastery seeks to podcast meaning into medical education by combining faith, high-quality lectures, and charity.”

====================================================

This is Part 2 of a telephone interview with Celeste Whisenant, a second year medical student.

She answers all the tough questions about what each year of medical school is like (at least year 1 & 2 that she knows about) and compares them to TV shows in some surprising ways.

This interview is part of the Grill the Guru series, in which I ask questions directly from the survey on medicalmastery.com.

Here is the rough outline of the questions I put together for this interview:

***Tell us about your self. “What school are you attending? How did you decide to attend that school over the other schools at which you were accepted?”

(we’ll have to explain the rank here)

***“What is med school really like? (as an ms1, ms2 etc.)” “What is the daily workload like? How much sleep do you get?”

***Is med school similar to what is shown on TV shows? (humor, the dating, drama, characters, hours, stress, family/home life)

***What do you know about D.O. schools, if anything?

Enjoy and email me if you have any questions!

====================================================

Mission Statement
“Medical Mastery seeks to podcast meaning into medical education by combining faith, high-quality lectures, and charity.”

====================================================

Topics in this podcast:

Announcements

Introduction of Celeste Whisenant - covered in the audio only

The Dreaded Interviewer - covered in the audio only

Current Strategy for the Medical School Match (Sign up for the Free eBook in the upper right and you will get access to photos of the ranking system online and learn exactly how to avoid the problem Celeste had.)

====================================================

Announcements:

The CD of the Month Club now off the market.

Live Webinar: get all your questions answered in one place - for FREE!
December 2, 2008 at 6PM Central time. Sign up for the Free PreMed eBook on
www.MedicalMastery.com and you’ll get an email with login instructions in the
days leading up to the seminar.

====================================================

Current Strategy For The Medical School Match:

In 2007, a major change occurred in the way Texas medical schools choose their students, more in line with what’s been done in the rest of the country. Prior to this change, students applied to the recommended 20-30 medical schools and waited for an interview. After interviewing at hopefully several places, students ranked their favorite schools (only those they interviewed at) electronically on a secure website.

Then, the student just waited for “match” day in early February.

Well, the game has changed and I want to give you some strategic tips on you should approach this for your best advantage. You still apply to the 20-30 schools and need to get an interview, which I have always felt is the biggest cut-off in the process. However, now it really has become a race to get absolutely the earliest interviews possible, especially if you really have a favorite medical school you want.

See, once the medical schools have met you at the interview they can send you an “Early Offer” giving you 2 weeks to go ahead and accept a position at that school. These offers are independent of any other interviews you may have scheduled.

For example, if you have an interview in October (one of the very first of the season) and the rest of yours are in December, the first school could send you an Early Offer. You have 2 weeks to accept it - before you’ve even interviewed at the other schools! If you say no and want to interview at the other schools, then that first school will include you in the electronic match (discussed in my Free eBook -sign up in the upper right).

The strategy I want you to realize is that as soon as interviews start in October, seats are filling up all over the country. Students are grabbing up the first opportunity to secure a position.

You should too.

Do absolutely EVERYTHING possible to go to the earliest interview date offered to you.

My recommendation is that the majority of applicants should accept the first offer they are given. The electronic match is now for the leftovers, those people that didn’t get any offers or refused them. The ones that refused offers are either completely stellar students that had other offers on the table or didn’t listen to this podcast.

Don’t decline your last Early Offer.

Take what you can get. You’ll thank me later.

====================================================

QUICK TIP:
So, what can you do about these changes? Here’s a checklist for you to follow:

__ Ask for letters of recommendation by February or March at the latest.

__ Submit your application to medical school during the FIRST WEEK they start accepting them.

__ Fill out and mail or electronically submit all secondary applications to medical schools that require them. (Check each medical school’s admissions website to download or read about secondary applications they may require. If there is any doubt, pick up the phone and call them! Are you beginning to fell my emphasis about how proactive you NEED to be?)

__ As soon as your application is submitted, check the website every day to make sure the medical schools have downloaded your application materials.

__ Finally - and MOST IMPORTANTLY, call each medical school you applied to. Tell them “Hi I wanted to make sure my application is complete and if there’s anything else I can provide because I am really interested in your school.”

====================================================

QUICK REFERENCE:
Are medical students meeting their best possible match? (2003 data)
http://www.siam.org/pdf/news/305.pdf

====================================================

Mission Statement
“Medical Mastery seeks to podcast meaning into medical education by combining faith, high-quality lectures, and charity.”

====================================================

ANNOUNCEMENT:

I’m almost finished with my complete, A-Z, PreMedical video tutorial course! If you’re not already one of the hundreds in the exclusive email list receiving chapters of my FREE PreMed eBook, sign up in the upper right of medicalmastery.com now. Very soon, only people who have signed up will get the details on this video course!

====================================================

This episode is the first in an interview series that was suggested by you - our listeners! Use the Grill The Guru survey on medicalmastery.com to submit your questions for future medical students and doctors I will interview.

Now, we’ll get right to the interview with Tyler Relph - a former PreMed tells us why he changed his mind. To hear the rest of this interview, join the CD Club online today!

Here is what he wrote and what we used as the outline for the interview. That is, until he turned the table at the end…

“I grew up playing soccer competitively, so the sports emphasis has always drawn me. When I was considering medical school, I was planning on going into orthopedic surgery followed up with a sports medicine fellowship. I wasn’t too concerned with the schooling I would go through, however the thing that made me call of my medical degree pursuit was the lengthy residency in conjunction with the 80 hour work week.

1. FAMILY - I’m married and have three children (3, 2, and a NB) If I were to go through medical school, I wouldn’t be an MD for 6-7 years (one year to finish up my bachelors, one year to finish up my prerequisites/ apply for med school, and four years of medical school). At that point my children will be 9, 8 and 6…then I start into my 80 hour work week as I venture into 3-7 years of residency (surgical specialty of some sort). Therefore, I wouldn’t be starting my practice until my oldest is 16. Through this possibly 13 year schooling journey, I believe I would miss out on my children’s lives too much to the point that it would affect them in a negative manner. I also have to consider time to continue to build into my marriage - to achieve my educational goals at the cost of my family is no success at all!

2. PAST EXPERIENCE - I have benefited from chiropractors immensely as I previously twisted my sacrum bad enough that I could barely walk. After seeing a chiropractor for about a year, I was able to join the military (i.e. all of the physical demands put on the body through physical fitness) and have no problems with my sacrum.

3. LIFESTYLE - Once again…it all boils down to family. I want to be able to be at home every night to ask the kids how their days were without the interruption of having to be called in. I can set my own hours - providing a two hour lunch break to be able to eat lunch with my wife and continue to build up that relationship. The money has very promising rewards - you work hard, the money will follow. Being my own boss and, if in a team practice, making the decisions with my fellow practicing chiropractors is “complete” freedom.

4. DURATION - The number of years of training - this brings me back to point one. By the time I am done with chiropractic school (with no residency of 80 hours a week), I will be thirty, at which point my oldest will be 8. This allows me to be entering into my practice when the children are still young, being able to nurture those relationships as the teen years begin to approach.

I will be attending Palmer West where a sports emphasis is available, in which students get to practice on professional athletes (currently the sports council is attending the Ironman competitions in Kona, HI providing chiropractic assistance to the competitors). Through this training, I will have the opportunities to work with professional athletes ensuring a healthy structural alignment to aid in the continuance of their careers.

Respectfully,
Tyler Relph”

I hope this interview helped you guys out. Visit medicalmastery.com and click on the survey on the right called Grill The Guru to get your questions answered.

====================================================

QUICK REFERENCE: links to tissue research foundation and other job-related PreMed activities can be found on Google.

====================================================

Mission Statement
“Medical Mastery seeks to podcast meaning into medical education by combining faith, high-quality lectures, and charity.”

====================================================

In this episode:

ANNOUNCEMENTS
PODCAST UPDATE
Pre-Med E-book now a 17-week FREE course
$0.01 Pre-Med CD lays the groundwork for EVERYTHING Pre-Med!
LISTENER REQUESTS
Q & A

====================================================

ANNOUNCEMENTS:

LEVEL 1: PODCASTS: I’ve had a slow pace with podcasts lately due to the pressure
of keeping up with residency. The newsletter has been reorganized to provide
continual email updates every 4 days, however.

LEVEL 2: NEWSLETTER: The FREE Pre-Med E-book had a fatal flaw. The newsletter
was cutting off the 50+ page Diary of a PreMed Student book around page 10 or
so. Thank you Mr. C. from Detroit, Michigan for pointing that out! There are
many other topics that get emailed to you in addition to the E-Book contents,
but it has been repaired to send you one of the chapters per week for a 17-week
course – all FREE!

LEVEL 3: CD OF THE MONTH CLUB: The MINDMAP is progressing nicely. This tool
organizes all of my Pre-Med content, and MANY topics not in the podcasts, using
an outline formatting software. For the first time you can have all of the
medical education websites, files, videos and podcasts all in one place! This is
only available through the CD of the Month Club. Sign up for my FREE Pre-Med
E-book at www.MedicalMastery.com using the attached file you get in my emails.

====================================================

LISTENER REQUESTS:

The survey on medicalmastery.com has sparked many questions, comments, and
suggestions for how to improve this Podcast. The most common request was for
more podcasts at more frequent intervals. Believe me, I’m doing the best I can
as a medical resident. I really enjoy helping Pre-Med students. It’s a passion
of mine and I look forward to staying involved with you guys in the future.

This podcast emphasizes the importance of asking your questions! NO question is
to simple. The only “dumb” question is the one you don’t ask. As you can see
there are all different levels of experience of the Pre-Meds that listen and
there is something here for everyone. Also, by asking your questions you are
helping each other out because you’re not the only one that wants to know. We’re
going to go through over 50 questions.

I am accepting introduction music submissions for an honorable mention. The
music has to be original, so if there are any musicians out there you are
invited to submit short music segments for introduction, special announcement,
and closing segments.

Listeners have also requested that I interview medical students and doctors.
Please submit questions for each. I want to make sure I ask them the things that
YOU most want to know.

If you have any other suggestions, visit medicalmastery.com and complete the
survey. Be sure to sign up for the FREE Pre-Med E-Book Newsletter.

====================================================

LISTENER Q & A’S

QUESTION 1: There were four similar questions –

Part A:

I am currently doing all basic classes including the basic sciences and my
intended major is Biology/premed and according to the UH NSM requirement I also
have to take a NSM capstone (which is either a double major, a minor, a thesis
or some research). But, after browsing the school website they have another
major that is interesting as well, its called B.S in Biology (medical
Technology) and it seems really interesting and the requirement are same except
their is a few more classes of chem but less math (all you have to do is cal 1)
but the last 30 hours are clinical programs. It sounds really interesting but
she told me that a lot of students that want to go into medicine do not take
this major! Is there a reason behind this? and plus do you think its a good
program? It also says that entry into a medical technology clinical program is
competitive, not a certainty. Although a minimum GPA average of 2.5 or better is
required by most medical technology schools. So, please let me know what you
think of this and let me know!!

ANSWER 1A

Congratulations on finishing another semester. By the way, I’m about to do
my next podcast that will answer your previous questions about which classes
to take and which schools to attend. The short answer is - choose your own
life! More to follow…

This is a very interesting question about the med tech curriculum. I say
that because it brings up a big concept in the admissions culture - program
hopping! See, this same question pops up when people transfer from Ph.D,
masters, nursing, or physician assistant programs and attempt to enter
medical school. The main question you have to answer is “why?”

What most advisors don’t demonstrate at the undergraduate level is a genuine
understanding of the CRITICAL health care provider shortage. If someone
takes up a seat in a competitive medical technology program and then doesn’t
fill that position in the community, but they change careers, per se, and go
into medicine, then they’ve wasted community resources.

Keep in mind, too, that state-supported schools (like UT and U of H) are
under a mandate to fill the shortage as efficiently as possible, or face the
threat of losing funding.

BUT HAVE NO FEAR

With the little bit I know about you, I already can see a bullet-proof plan
that will cement your entire application and undergraduate experience (at
least on paper). Are you ready?
1. Do whatever is safest and most convenient for you this summer.
2. Stick with whatever undergraduate major YOU like the most. Do the med
tech program if it sounds interesting enough to finish.
3. In your personal essay, state that you have an interest in pathology and
that is why you chose that major. You’re not lying, after all. Plus, if you
change your mind later, it’s a great career.
4. When your grades gain steady improvement, site that semester as the time
in your life when you decided to pursue medicine in all seriousness.
5. When you come back from India, step up your academic game and treat it
like a job.
You can do it.

Part B, C:

Transformation from RN to MD and the reality of it. Please
include experiences from medical school students. What do medical schools think
about nursing majors who are going into medical school?

Part D:

I want to learn about the MCAT prep and advice on choosing
a major for a BA or BS degree.

QUESTION 2

I was wondering if you had any references for me in order
to beef up my knowledge of healthcare policy and issues in the US (and maybe
abroad)? I would really appreciate any sources, or if you could point me in the
right direction.

ANSWER 2

What are you most interested in learning about? Just basic stuff to be
knowledgeable for interviews or something more serious for career aspirations?

My first thought is to subscribe to newsletters/magazines such as American
Medical News (by the AMA). I get this and that’s what they’re all about. They
represent 25% of US physicians and they’re all about policy.

QUESTIONS 3-49: From The Online Survey

The $0.01 first CD contains the answers to the following
questions:

• Video Tutorial: Getting Organized lecture, presented at the University of
Houston’s American Medical Student Association’s PreMed chapter.
• Audio MP3’s: About Medical Mastery, Admission Requirements, Letters of
Recommendation, and Medicine as a Career
• Study Material: Biostatistics, Definitions and Differentials, Ethics of
Healthcare Organizations, Neurology Questions parts 1 and 2, Research
commentary, Statement of the definition of true science, Somatosensory Pathways,
Processes and Systems, Statistics PowerPoint, and the USMLE eBook.

• What the admissions committee is looking for and tips
for the interview.
• Getting the residency you want and information about the Personal Statement.

• Second Edition Diary of a PreMed Student
• Checklist: Getting Organized
• Show Notes: Getting Organized
• Articles: US, UK, Canadian med student career choices, Letters of
Recommendation
• MCAT: Biochemistry Questions and Answers
• MindMap Contents:

• Advice about medical school preparation, especially
comment on consistency and reliability.

i. 1. Getting organized: graphical and narrative descriptions of the Master
Application Binder
ii. 2. Professional Email Account references. Make sure the email account you
use doesn’t have an embarassing title that the admissions committee might
notice.
iii. 3. A reference tool for Password Organization. Welcome to modern medicine -
be prepared to have to remember more ID’s and passwords than humanly possible.
iv. 4. Transcript request template.
v. 5. Address label template.
vi. 6. Transcript follow-up checklist template.

• How graduate GPA factors into the equation for medical
school and MCAT tips.

vii. 7. Official GPA calculations of the American Medical College Application
Service, including a graphical insert from my actual application and a
narrative.
viii. 8. A Microsoft Excel GPA calculator template for you to manipulate to
predict what your GPA will be come application time.
ix. 9. Sample list of academic honors important for you medical school
application.
x. 10. Resume template.
xi. 11. Sample phrase for volunteer community activities.
xii. 12. Undergraduate research description samples.
xiii. 13. My personal essay.
xiv. 14. My entire medical school application. See all of the biographical and
personal questions you have to answer in advance! There is a lot more to write
than the personal essay.
xv. 15. Secondary application essays. Most medical schools require an additional
application, besides the centralized application service, which comes with
multiple short essays.
xvi. 16. Medical School Application Summary Page (sample). Get an inside look at
the application cover page that admission committees see first!
xvii. 17. The original diary of a PreMed student, unedited and written while on
the medical school interview trail.
xviii. 18. Medical School Essay – HELP. 10 steps to writing the personal
statement along with 5 DO’s and 5 DON’Ts.

• How much do my goals for my career affect my chances of
being accepted and an assessment of how competitive my application is right now.

xix. 19. My Practice Vision: The second personal essay. The general question is
“How do you see your career playing out 5-10 years after medical school?”
xx. 20. Checklist for writing the personal essay.
xxi. 21. How to get STRONG and plenty letters or recommendation.

• What is the best way to log volunteer hours? I mean, is
it a cumulative report from the beginning of undergraduate or is any work done
prior applicable as well?

xxii. 22. The coveted letter for an invitation for an interview (sample now an
expanded section!).
xxiii. 23. Common details about interview details (sample itinerary).

• Information about non-US medical schools, particularly
Caribbean schools.

xxiv. 24. List of Caribbean Medical Schools
xxv. 25. Medical school admission requirements.
xxvi. 26. List of Allopathic medical schools
xxvii. 27. List of Osteopathic medical schools

• How do you start to become a doctor and Pre-Med?
• What are the steps to become a doctor for someone who has NO education (at
least on paper)? Where do I start?
• How do I keep myself motivated…I know this is what I want to do but other
students always seem to keep discouraging me.

xxviii. 28. Deciding on a career in medicine (article)
xxix. 29. Personal essay (sample) for MD/PhD program
xxx. 30. The Modern Medical Scrolls E-book. 1,275 pages of medical student notes
written for each other…and themselves. This .pdf file contains the parts of
medical school that you’ll actually want to remember!

CD Number 2 contains the following answers to your
questions: subsequent CD’s are only $17!

• How can nontraditional applicants create a competitive
AMCAS application and how do I maximize the personal statement and interview to
express my viewpoints.

• Video Tutorial: How to write the Personal Essay in 10 Steps. Also, 5 DO’s and
5 DON’Ts!

• How do I compensate for a low GPA? How do grades from a
harder school compare to presumably easier schools? Besides the MCAT, are there
other ways to demonstrate academic strength? Do the admissions committees
already understand these discrepancies and account for them when reviewing
applications?
• Overcoming a low GPA (under 3.4). How to get back into the swing of things
after a break from school.
• How do community college courses affect your chance of admission?

• Audio MP3’s: The Perfect GPA: No matter what your grades! Sound ridiculous?
• Study Material: Chest x-ray primer, EKG primer, Most Common Female
Reproductive Problems, Hemorrhage, History and Physical Checklist, History and
Physical Pocket Card, Hormone Chart, Psychological Assessment, Tachyarrhythmias
101
• Checklist: The Personal Essay.
• Articles: Euthanasia, Neurenberg, The Personal Essay, Threats To Validity
• MCAT: Pathophysiology

• Getting into medical school in general and specifically,
how much is medical school going to cost me.

• MindMap Additions: The Perfect GPA, Military Experience, Financial Assistance

CD Number 3 contains the following answers to your
questions: subsequent CD’s are only $17!

• How to improve my chances of getting into medical
school.
• How do I get my application recognized among the rest?

• Video Tutorial: The Construct – Part A. Write
your entire medical school application way in advance! Now!! Think through every
step of the process and use this to objectively assess the strengths and
weaknesses of your application.
• Audio MP3’s: Financial Assistance, The Construct – Part A.
• Study Material: Basic Eye Exam, Blood Smear, Dermatology – Skin Neoplasms, Lab
Values 101, Moguls – heart shadows on x-ray, Neuroradiology, Opthamology
• Checklist: The Construct – Part A.
• Articles: False Hopes – Best Data, Human Subjects Research Training, Research
Commentary, Research Description (sample) Teaching Evidence-Based Medicine,
Threats to Validity.
• MCAT: General Chemistry.

• What do you think about post-bacchleurette programs?
Speak about master’s programs before entering medical school for someone that
needs to enhance their academic background.

• MindMap Additions: Research: The Role Of Research In Your Medical School
Application.

CD Number 4 contains the following answers to your
questions: subsequent CD’s are only $17!

• Video Tutorial: The Construct – Part B. Write
your entire medical school application way in advance! Now!! Think through every
step of the process and use this to objectively assess the strengths and
weaknesses of your application.
• Audio MP3’s: The Construct – Part B, Financial Assistance.
• Study Material: Infrared Spectroscopy parts 1-3, Mental Status Examination,
Renal Disease Chart, Stem Cell Research, Vitamins, History of Present Illness (HPI)
and assessing the patient’s mental status.
• Checklist: Financial Assistance Opportunity Exploration, The Construct – Part
B
• Articles: Financial Assistance For Medical School: An oxymoron?, Medical
Futility, Suicide, The Tarasoff Case, The Ethics Movement
• MCAT: Physics

• The interview process and comment more about the path of
the nontraditional student.
• How to make my application standout and how to get an internship or shadowing
opportunity as an undergraduate.

• MindMap Additions: Having a Successful Interview, Volunteer Activities, Uncut
Interview Diary, Diary of a PreMed Student (2nd Edition Guide), Interview Topics
(85 pages!).

CD Number 5 contains the following answers to your
questions: subsequent CD’s are only $17!

• Is it worth taking the MCAT for the third time?
• How should a Pre-Med student study and/or practice for the MCAT?

• Video Tutorial: How To Study For The MCAT And More: The Proven 5-Step Study
Method
• Audio MP3’s: How To Study For The MCAT And More: The Proven 5-Step Study
Method
• Study Material: Neonatal Resuscitation, Behavioral Science Part A, Behavioral
Science Part B, Psychiatry Review
• Checklist: Maximizing Your Study Methodology
• Articles: 100 Years After The Flexner Report, Feedback In Clinical Medical
Education, Impact Of Formal Continuing Education, Systematic Review Of Physician
Performance
• MCAT: Biochemistry Part A, Biochemistry Part B, Evolutionary Questions
• MindMap Additions: How To Study For The MCAT And More: The Proven 5-Step Study
Method

CD Number 6 contains the following answers to your
questions: subsequent CD’s are only $17!

• Video Tutorial: The Power Of Exploiting Your Competition & Demonstration Of
Navigating The MASTERMIND Map.

• I really would like some more information regarding your
thought process upon your decision to leave the military and pursue a career in
medicine. Also, how did you articulate your experiences in the military in your
application/personal statement? What type of responses did you receive from
medical schools regarding your military experience?

• Audio MP3’s: Opening Lecture at the University of Houston Pre-Med Club, The
Power Of Exploiting Your Competition & Demonstration Of Navigating The
MASTERMIND Map.
• Study Material: Antibiotic Medications, Anti-Mycobacterials, Neuroscience
Review, Parasite Note Cards
• Articles: “I Don’t Know” – The Three Most Important Words In Education,
Learner-centered Approaches In Medical Education, ECFMG Information Booklet and
Certification Fact Sheet.
• MCAT: Pathology
• MindMap Additions: Legal Documentation, Work History Template, References,
Certifications, The Professional Email Account, Journaling, Extracurricular
Activities

FUTURE CD TOPICS:

• Also, are the MCAT preparation courses worth the money?
• Interviews with doctors for comparison of what I’ve heard and insight on the
application and interview process.
• What admission officers DON’T want you to know about the process and some big
misconceptions about medical school.
• The reality of medicine. What being a doctor means? I mean, tell me about the
day-to-day goings on of an actual doctor, not what is shown on television.
• What about the “unprepared” medical student that didn’t decide to become
Pre-Med until after college and therefore didn’t take advantage of a true
academic advisor?
• LAST BUT NOT LEAST: insider medical school practice tests – the real thing!

====================================================

Mission Statement
“Medical Mastery seeks to podcast meaning into medical education by combining
faith, high-quality lectures, and charity.”

====================================================

In this episode:

ANNOUNCEMENTS

PREPARING: What is my competition doing?

HOW TO GET A STRONG LETTER

TO SEE OR NOT TO SEE: There is no question.

WHEN TO ASK

QUICK TIP: Questions to ask in order to choose the right letter writer.

QUICK REFERENCES

I am your host, Daniel Williams, MD.

ANNOUNCEMENTS:

1. MICU month - hanging in there…

2. The PreMed Lecture Series. It’s going well and I now have an entire system for premed students to compile their entire medical school application 1-3 years in advance! Why wait? Write it now. Have it reviewed by me and faculty over a longer period of time greatly increases the power of the application, demonstrates a motivated, clearly goal-oriented candidate, and will increase your chances of getting accepted into medical school.

Many have expressed concerns about weaknesses in their application, such as failing or close-to-failing grades, or poor MCAT scores.Folks I overcame these obstacles and you can too! These questions are all being addressed in my coaching course and I want to personally review your application contests. From your personal essay, to the way you describe your work history - I want to see it.

Sign up for the automatic updates on www.MedicalMastery.com and you will be on the early notification list for the details about this coaching course as the next course approaches. This year I’m automating the coaching coarse complete with audio/video how-to tutorials, checklists for every step of the way, my entire medical school application to be used as a template, personalized feedback on your application and much more! Sign up today!

3. Diary of a Pre-Med: A 16-Step Guide. This book is available for free and emailed to you immediatly after you sign up for automatic updates on www.MedicalMastery.com. This is the first edition book that I wrote as a 4th year medical student as a result of my collaboration with premedical students. Of course, the coaching course that you’ll hear about through that email newsletter is the steroid-version! Sign up free right now!4.

Get my favorite 2,500 MCAT questions on CD-ROM for only $27. Get your MCAT Questions by clicking “BUY NOW” in the upper left of this website!

Satisfaction GUARANTEED or your money back! Send it back if you don’t like it and get a full refund…NO RISK.

====================================================

PREPARING: What is my competition doing?

Getting any letter of recommendation (LOR) from a physician or undergraduate faculty can by daunting. With limited face-time, busy schedules, and such high expectations for a LOR, how in the world are you supposed to get 3, very solid, letters from reputable doctors?Let’s start with a discussion about the “PreMed Committee”. This is actually an official entity that medical schools care about (not necessarily anyone else). It is made up of a (somewhat) official Premedical Academic Advisor and 2 underlings, which are often other faculty.

In the late ‘90’s and early ‘00’s, this was still a robust entity found in all but the smallest colleges.There have been massive cutbacks in funding nationally and the result has been fewer and fewer committees that actually know the real scoop. Some of them are registered members of the National Association of Advisors for the Health Professions. This organization attempts to educate non-physicians about the premedical application process. While this is better than nothing, they don’t know what they’re talking about from first-hand experience.In short, get your letters of recommendation from members of your PreMed Committee if you have one PLUS one from a physician.You typically want one from your advisor and 2 from faculty ( the standard carte blance answer). I say if a physician doesn’t write you a letter you’re shooting yourself in the foot.Sidestep all the guesswork on the part of academic advisors and get a physician to evaluate you.

Of course, the quality of the letter is the most important thing.If the strongest letter is from your postman, that’s the one you want! More about that in a minute. I still say that getting to know and perhaps shadow a physician is the best way to get the strongest letter.

HOW TO GET A STRONG LETTER

Relationship matters! You don’t want any old letter of recommendation. You want a “strong” letter of recommendation. What’s the difference?

When you approach a potential letter-writer, you should ask “Are you able to write me a strong letter of recommendation?” Physicians and faculty know that this little adjective means, perhaps more than you do, so make sure you say it that way. If they hesitate, decline, or in any way don’t convince you that they will write a strong letter, then don’t use their letter!Give the writer a copy of your resume or CV, transcript, research papers, and any other documentation that will allow them to see parts about your application that they would have no other way of knowing about.

TO SEE OR NOT TO SEE:

There is no question.Once you find the right person to ask, you will give them a standardized form from the AMCAS. It asks them specific questions about their relationship with you, projects they worked with you on, and how long they’ve known you. This is why it’s important to meet and start grooming someone early that may be able to write you a letter.

There is a section on the form for you to sign. Here you have the ability to waive the right to see the letter. Virtually everyone waives it because the medical schools prefer it that way. This way the writers feel free to put negative comments if they want. Of course, you don’t have to worry about that because you have known them and worked with them for a long time and specifically asked them if they could write a strong letter. They said yes! Go ahead and waive.

It is polite to write thank you notes for many occasions. Writing one to letter writers and interviewers is no exception. Do this as a common courtesy.

WHEN TO ASK

When to ask – start a relationship early, they ask how long. Relationship is harder than getting the letter. The letter should be a natural step in your relationship. You can ask early in undergrad before they forget you. They will at least take notes on your packet and write it later, so that it will reflect a more recent date by the time of the application.

====================================================

QUICK TIP:

When selecting someone to write you a letter, consider the following:

• Have they written letters of recommendation before?

• Is this a physician that practices as some small independent place and would, therefore, have no real idea what admissions committees are looking for these days?

• Do you have a good, close working relationship with them, or do they not even know you by name for whatever reason? (large university, no collaborative research projects, mediocre student…)

QUICK REFERENCE

Here is more than you want to know about the recent FAQ’s regarding medical school application letters of recommendation:

http://www.aamc.org/students/amcas/amcaslettersfaq.htmShopping for a PreMed advisor? See if your local university even has one. Here’s a link to see what pre-med advisors are telling each other:

http://www.naahp.org/resources.htm

====================================================

Charity of the Month for April 2008: WarmBlankets.org will receive all donations made in the upper left hand corner of www.MedicalMastery.com.

Charity Mission Statement”

The mission of Warm Blankets Orphan Care International is to restore the lives of orphans in partnership with churches, corporations, organizations and individuals who have a passion to help needy, parentless children.

“Testimonial”Religion that God our Father accepts as pure and faultless is this: to look after orphans and widows in their distress and to keep oneself from being polluted by the world.” - James 1:27″

====================================================

Mission Statement

“Medical Mastery seeks to podcast meaning into medical education by combining faith, high-quality lectures, and charity.”

• Words of advice
• Questions that identify your preparedness for a career in medicine
• Importance of life experiences
• QUICK TIP: Things you can do right now do help you decide if medicine is right for you
• QUICK REFERENCE:
  • Stimulating research papers on US, UK, and Canadian medical students’ career choices
  • 3 career questionnaires

Let me preface my remarks by saying that from now on you should avoid career advice from anyone that has no experience with medical school. This includes family, friends, professors, and sometimes Pre-Med Advisors. What many notice is that people often project their own impression and reasons that they chickened out and didn’t follow their dreams onto the enthusiastic Pre-Med student.

Word of advice: Ignore the crotchety old doctor that tells you not to do it because of the influence of insurance and governmental regulations of recent decades. Not that you would listen to them, but if you educate yourself on the market you’re entering and still want to do it, you won’t have to.

When you account for the diversity of people entering into the medical profession, the reasons that they site for becoming interested vary widely. Some have people have always known they wanted to practice medicine, others are not so sure, and still others decided a little (or a lot) later in life. Whatever your background, I support you! None of these approaches will hinder you from reaching your goals.

So consider your sources carefully! This is all the more reason to plug into Medical Mastery.com and read our insiders advice and get automatic email updates!

So, how in the world are you supposed to know if medicine is right for you? Open a new text document or grab a pen and answer these questions:

• Are you the type of person that gives of yourself to help others?
• Do you receive satisfaction in helping someone when they’re down? How do you really know? Have you done it?
• Would you consider yourself a concrete, logical thinker or an abstract thinker?
• Have you had any exposure to the medical field, either through family or volunteering?
• Do you complain a lot when you’re tired? Have you ever really worked hard before?
• Have you ever been challenged academically? To the point that you weren’t sure if you could survive?
• Have you ever had a life challenge that lasted months or longer? (financial, stress, family illness…)
• Have you ever been financially challenged, or have you always had a stable life?
• Do you know what it feels like to be a helpless patient?

These questions should stimulate your mind and, if so, take notes! How did you react when you read them? Did you have quick, pat answers for every one? Did you think that some of them were irrelevant? Your reaction is important, no matter what it is because you can learn something about yourself!

You may notice that many of these important factors don’t illicit the warm and fuzzy feeling that you may have had when thinking about the nobility of the medical profession. That is because the practice of medicine, though it is noble, focuses on helping people in their greatest need.

If you haven’t had any of the down-and-dirty experiences of life, you’re at a disadvantage to knowing how well you’ll like medicine. You have no way of knowing either how to relate to the patients or how you’ll react when you’re around them all the time. That doesn’t mean that it’s not right for you, only that your ability to know how well you’ll like it ahead of time is impaired. The best you can do is volunteer in shelters, emergency rooms, shadow doctors, and the like. This is adequate for most people, but you should be at least mentally prepared for what you’re getting yourself into. (which is why you’re reading this, isn’t it?)

THINGS YOU CAN DO NOW:

Write a draft of your life goals

Decide what your ideal lifestyle is

Read articles

Shadow physicians

Volunteer

Research

====================================================

QUICK TIP:

Career decisons are more about clarifying who YOU are rather than learning about the career itself. So as you begin exploring the references I’m about to give you, make notes of character descriptions or epiphanies that you have. You will learn how to better articulate what motivates you as you resonate with some of the personality descriptions that you’ll see. Keep these notes in a file. No matter what career you choose, you can find some good phrases to swipe for resumes, cover letters, and personal essays. In fact this is the first step in writing your personal essay - brainstorming and articulating who you are!

QUICK REFERENCE:

USA medical students: http://www.stfm.org/fmhub/fm2004/February/Janet123.pdf

Canadian med students: http://www.pubmedcentral.nih.gov/picrender.fcgi?artid=1930324&blobtype=pdf

UK medical students: http://www.pubmedcentral.nih.gov/picrender.fcgi?artid=1239861&blobtype=pdf

Career Questionnaires:

http://virtualmentor.ama-assn.org/2006/08/msoc1-0608.html

http://www.aamc.org/students/considering/decision.htm

http://www.free-career-test.com/tfct.asp

http://www.projectcareer.com/?code=G71-CPC50701-Career&gclid=CPLI5KWolpICFT00FQod9gMA_g

====================================================

Charity Highlight: Overcomers

Charity Mission Statement

“Overcomers exist to bring hope to hurting people and equip those who care with the knowledge needed to make a difference in other’s lives. Founded on the conviction that no matter how desperate life’s challenges may be, in Jesus Christ there is always solid reason to be optimistic.

We are a teaching ministry: educating people how to encourage each other in the love of Jesus Christ when facing life’s onslaught’s. Imparting the tools needed to comfort and help others with what to say and not to say. We formulate DVD courses to teach lay people across the world how to bring comfort and encouragement and the love of Jesus Christ to all.” http://www.overcomers.org/index.html

Now, reading the lists of medical school entrance requirements is dry. As much as I have tried to avoid using boring lists, they simply can not be avoided when discussing the subject of entrance requirements for medical school.
COMPONENTS OF THE MEDICAL SCHOOL APPLICATION:

• Demographic Data (some of it is optional)
• MCAT - submitted indirectly by the New MCAT Testing History (THx) Report System.
• Official DAT/MCAT/GRE/ACT/SAT Score Reports
• Personal References
• Letters of Recommendation/Evaluation - provided by application service
• Personal Essay
• Volunteer, Research, Work Experience
• Application Fee
• Certification Page
• Photos
• Copy of Visa or Permanent Resident Card (if applicable)
• Secondary Applications

Undergraduate Prerequisites:

• 30 credit hours minimum (unwritten requirement for a bachelor’s degree)
• 1 academic year of Physics
• 1 academic year of Biology
• 1 academic year of General Chemistry
• 1 academic year of Organic Chemistry
• 1 academic year of English

Additional courses are sometimes required. The most recent statistics are from 2005 (yes I know it’s 2008) and they show some medical schools requiring college mathematics, calculus, humanities, biochemistry, and behavioral sciences. Other helpful courses are computer science, genetics, and statistics.

For the MCAT itself, advanced courses in literature interpretation and critical reading will help science major perform better in the Verbal Reasoning section.

Unfortunately, the list of undergraduate courses required varies among the schools themselves. It doesn’t pay to memorize these lists. We recommend that you obtain hard copies of the school catalogues from the institutions that interest you. You can search a specific medical school for its entrance requirements here: http://services.aamc.org/currdir/section2/courses.cfm.
Personal attributes are increasingly important and medical school applicants are under intense scrutiny in this area. Here’s a list of more intangible qualities that medical school admissions committees are looking for in a candidate:

• Altruism
• Compassion
• Humility
• Practical application of knowlege: wisdom
• Life Experience
• Demonstration that you know what you’re getting yourself into
• Knowlede of our nation’s health care crisis
• An idea of what you want your life to be like - take a wild, but honest guess.

====================================================

QUICK TIP: You’ll need these too:

• Access to a computer that is able to connect to the internet
• An e-mail address is required
• Applicants must use only Internet Explorer or Netscape Navigator exclusively to complete the application . Do NOT use Mozilla/Firefox (TMDSAS)
• A laser or ink-jet printer is required to print the Certification Page, Health Professions Evaluation Forms and Transcript Request Forms

QUICK REFERENCE: Application Services

Investigate information about medical school application services:

• American Medical College Application Service (AMCAS)
• Texas Medical and Dental Schools Application Service (TMDSAS)
• Ontario Medical School Application Service (OMSAS)
• American Association of Colleges of Osteopathic Medicine (AACOM)
• American Association of Colleges of Osteopathic Medicine Application Service (AACOMAS)
• AAMC Curriculum Directory for information about medical school curricula and joint, dual, and combined-degree programs.

====================================================

Charity of the Month: Global Tribe - March 2008. Global Tribe will receive all donations made through the “DONATE” button at the top left of this page.

“The mission of Global Tribe is to actively participate in God’s grand plan for every tribe, every tongue, and every nation by building an army of thousands globally who will intentionally declare war on poverty - both physically and spiritually.” (www.GlobalTribe.com)

Anthony Walton, President, Global Tribe: “As a long-time pastor in New Zealand and missionary to many countries, I am so pleased to be a part of what God is uniquely doing through Global Tribe. My heart has always been for the poor, whether those in extreme physical poverty or those in spiritual poverty. GT is identifying and addressing the major issues in all cultures around the world like poverty, HIV/AIDS, social injustices, and caring for orphans around the world. The disenfranchised of the world have a friend in Global Tribe.”

====================================================

Mission Statement
“Medical Mastery seeks to podcast meaning into medical education by combining faith, high-quality lectures, and charity.”

Depending on your source, statistics will tell you that only one in ten premed students in college will actually become physicians. According to the American Association of Medical Colleges, 42% of you will actually get accepted. That number is actually high because so many people change their mind and don’t follow through with the application process. There are many reasons for this. In this lecture series, we will explore all of the ones that I get emails about.

Hello, I’m your host Daniel Williams, MD.

Disclaimer

• Raw and uncensored
• Good, bad, and ugly
• No offense intended
• Only my experience

Preview

• I was an Emergency Medicine resident when I started this podcast
• I love my job and wouldn’t want to be doing anything else
• What I do is nothing like the movies
• You can’t make up the things I see
• You wouldn’t want to

Who is this guy, anyway?

I come from a family without college degrees. I knew no one closely that had been through medical school. If I can do it, you can do it! I partied a bit much in high school. Then I Worked in a warehouse. Later, I joined the Army with NO college, as an E1. Those of you that have been in the military know what that experience is like.

On a medical mission to Benin, Africa I got interested in medicine. Specifically, helping the world’s truly needy people. Later I discovered ways that needy populations are served by…THE INTERNET!

I got out of the Army and attended a undergraduate university that had a certified pre-med advisor that attended the state-wide conferences. My MCAT was pretty bad - 26/35. When I got the score in the mail I was depressed for 3 days and didn’t want to talk to anyone or get out of the bed.

What had I done?

I left the Army for this? Took less money for this? Got a degree in Biology that I couldn’t use to mount a decent career, at least not compared to being a physician. I had taken a big risk (on myself), poored in a lot of money and time into extra, “Pre-Med Prerequisite” courses, not to mention the pain of actually trying to do well in them.

Then, the worst blow…my advisor told me to consider another career because of the predictive nature of the MCAT.

Obviously the story doesn’t end here. What happened that changed the course of my career? That’s exactly the point of this article!

My Pre-Med club was active and we toured 4 medical schools in 5 days! Getting to speak with current medical schools was entirely different than anything I had heard. Hearing the insider information changed EVERYTHING!

So, I prayed a lot, then gathered my strength. I decided not to listen to anyone but an MD or a medical student. I even ignored my own father’s misgivings and speeches about how difficult the years of training would be. He just didn’t get it. I’m doing what I love! Without exception, the people that had negative things to say about my choice to be Pre-Med were people that were not fulfilled in their own lives. I had grasped the life lesson I needed to succeed! My mindset was finally right.

I learned everything I’m about to teach you in this course.

As time went on, I began to wonder if others had my experience. I was fortunate to be in an active Pre-Med club with an concerned, participating advisor! What’s happening in other places?

Well, in the Army I learned to take care of my subordinates’ needs. In medical school, I naturally spent 4 years working on the student web site. Pre-Med student from in and outside the U.S. contacted me through Google searches and asked for advice. That’s when I wrote the Pre-Med Entrance Guide I email to those that get automatic email updates to MedicalMastery.com. This blog post podcast marks the first of my years of experience and tremendous collection of electronic notes.

Nowadays, I’m personally taking 10 people per year on a guided coaching course through the entire Pre-Med process, from A to Z! Starting each June! More details will be released as the time approaches.

What do I do in my spare time? Besides spending time with my family, I give tours of the schools and cadaver labs, National Youth Leadership Program cadaveric airway labs, Dr. Reye’s High School Program tours and Q&A sessions, and ACLS instruction.

Mission Statement
“Medical Mastery seeks to podcast meaning into medical education by combining faith, high-quality lectures, and charity.”

• a continuous process in the testis
• in a normal male, there’s always mature sperm-in time.
• in space, there are cells at different stages of maturation
• continuous in time but discontinuous in different places along the seminiferous tubules

Looking at x.s.

• the spermatogonia are closest to the basement membrane
• the mature sperm-spermatozoa-are closest to the lumen of the seminiferous tubules
• Test question-there’s three processes to spermatogenesis-1) mitosis 2) meiosis 3) spermiogenesis
• To get from the spermatogonium, to spermatid, to spermatozoa
• spermiogenesis-morphological change from the spermatid to the mature spermatozoa
• this takes morphological and biochemical changes, not mitotic or meiotic
• SPERMATID à MATURE SPERMATOZOA
• note-to get from the spermatogonium to spermatid, you need the mitotic and meiotic processes
• spermiation-the release of mature sperm into lumen
• mitosis à meiosis à spermiogenesis
• Process up to primary spermatocyte involves mitotic events-that is, conversion from spermatogonium to primary spermatocyte is done via mitosis
• In pre-pubescent boy, there’s only Sertoli cells and spermatogonium
• everything’s arrested until puberty-and surges in testosterone
• Conversion of primary spermatocyte to secondary spermatocyte is meiosis I
• meiosis I, the first maturation division
• Meiosis I: primary spermatocyte à secondary spermatocyte
• Conversion of secondary to spermatid is meiosis II
• Meiosis II: secondary spermatocyte à spermatid
• Then, spermiogenesis-this where the flagella is produced

Six true divisions of spermatogenesis-six true “families” of cells that become sperm

sertoli cells à spermatogonium à primary à secondary à spermatid à spermatozoa

• Males reproductive system is like a tube-seminiferous epithelium lumen, vas deferens, epididymis, urethra
• Blood-testis barrier-a function of the sertoli cells(non-germinal element of the seminiferous epithelium)
• sertoli cells, also nurse cells,
• germ cells literally pushed into the cytoplasm of the sertoli cells, the same as if you took the Pillsbury Dough Boy and went poke into his little tummy, made indention, then put marble into it-marble is the germ cell
• Between individual sertoli cells, there are tight junctions-they act as a barrier between the seminiferous epithelium from the great lumen
• The microenvironment in the basal compartment is very different from the semi-lumen compartment

Nondisjunction-occurs during meiosis in the oocytes

• Trisomy 21-Down’s Syndrome-failure of meiosis in the egg
• results in some brain retardation, infertile progeny, heart problems, etc.
• Amniocentesis and chorionic villi used to detect
• 45XO, Turner’s Syndrome-no ovarian development
• woman looks pre-pubescent
• Woman with Down’s Syndrome can now become pregnant-do produce own eggs-they just need influx of hormones to induce proper ovulation

• During ejaculation, a male sends out anywhere from 100-300 million sperm
• 20 million per ml is getting to the point where fertilization will not happen
• Sperm aren’t fully capable of fertilizing when they are ejaculated
• As they move through the vagina and passages, they are capacitated
• proteins removed, etc..
• Capacitation is defined as the final step of sperm maturation consisting primarily of changes in the acrosome that it prepare it to releases the enzymes required to penetrate the zona pellucida, a shell of glycoprotein surrounding the oocyte
• THE SPERM GETS CAPACITIZED

Questions

Which two substances inhibit GnRH secretion?

Dopamine and endorphins

What neurotransmitter stimulates GnRH secretion?

Norepinephrine

What is the rate limiting step in LH and FSH production?

GnRH dependent availability of the Beta subunit

What does GnRH require for its biological action on gonadotrophs?

Ca

Describe the GnRH to gonadotroph binding and activation process.

GnRH attaches to a plasma membrane glycoprotein receptor and, after binding Ca,

calmodulin acts to alter the activity of enzymes and cytoskeletal proteins involved in the

process.

What is the rate of release of LH and FSH during the follicular phase?

One pulse per hour

What controls gonadotropin secretion during the follicular phase?

Negative feedback of estradiol

What causes the midcycle gonadotropin (LH) surge?

Positive feedback action of estradiol

What hormone facilitates the release of LH and FSH during the midcycle LH surge?

Progesterone

Does the GnRH pulse frequency increase or decrease during the luteal phase?

Decrease

What hormone(s) are responsible for this?

Progesterone and endogenous opioids

How do you treat Kallman’s Syndrome (1^o hypothalamic amenorrhea)?

Exogenous GnRH pulsing

Why is hyperprolactinemia frequently accompanied by hypogonadism or amenorrhea?

Prolactin in excess shuts off pulse generator.

What percentage of germ cells are ovulated in the normal female?

0.1%

About what % of oogonia are produced after a woman enters puberty?

O%

Dose the process of Prophase I to Metaphase II occur before or after the LH surge?

After, it is what initiates the resumption of meiosis.

Which type of follicle can be identified by the presence of Call-Exner bodies?

Graffian or antral follicle

The innermost granulosa cell layer is called the …

corona radiata

What is the most mature stage of a follicle that can be achieved in a pre-pubertal

­ female?

Pre-antral follicle.  The graffian follicle requires FSH and thus a mature hypo-pit-ovarian

axis.

T or F.  Folliculogenesis is linked to hormonogenesis in the ovary?

True

The aromatase system that converts androgens to estradiol is LH or FSH induced?

FSH

What is the underlying factor in the elevation of estradiol levels that triggers the LH

surge?

Size & growth of the pre-ovulatory follicle.

What are the 4 oocyte extrusion mechanisms theorized?

1) proteolytic (plasmin)

2) mucification

3) muscular (tension)

4) angiogenic & inflam.

What is the non-pregnant life span of the corpus luteum

14 days

What are the corpus luteum granulosa cells dependent upon for the synthesis of

progesterone?

LDL

T of F. Progesterone is secreted by the corpus luteum in a pulsitile fashion?

True.  Reflective of the LH secretion that the corpus luteum is dependent.

What drug do you give for anovulation?

Clomiphene

Does the estrogen:progesterone ratio change before labor, in humans?       NO

In sheep?                                                                                            YES

What plays an important role in the stimulation of myometrial activity in humans?

PGs

How do the myometrial cells communicate with one another?

Gap junctions

What stimulates gap junction formation?

Estrogens and PGs

What inhibits gap junction formation?

Progesterone & Indomethacin

What substance acts to decrease intracellular Ca?

cAMP

What acts to increase intracellular Ca?

PGs, oxytocin, IP₃, & channels

How does ritodrine act to stop labor?

Activates adenylate cyclase Þ increased cAMP

Name 2 other drugs used to stop labor.

MgSO₄ & Nifedipine

Which Disorder do you treat with oxytocin, Prolonged latent or Protraction disorder?

Prolonged latent

What is the most important factor in Fetal Acid-Base Balance?

Uterine-fetal blood flow

What helps cause the pCO₂ gradient between fetal and maternal circulations?

Maternal hyperventilation

What is the maternal compensation that occurs in response to the fetal kidneys not being able to handle non-carbonic acids like uric acid?

Increased maternal GFR

T or F.  Normal labor is associated with a ß pO₂, ß pH, ß HCO₃, Ý base deficit, & an Ý pCO₂.

True

Which stage of labor ends with complete cervical dilation?

Stage I, active stage

Which stage of labor ends with delivery of the placenta?

Stage III

T or F.  To end stage III of labor so you can get back to your repro studying, just pull on the cord until it comes out.

False.  Will cause inversion of the uterus and hemorrhage

How many total number of consecutive divisions take place to get to the term fetus?

42

T or F.  Mothers tend to have wide variance in their offspring’s birthweight?

False, you silly goose.

What is the limit of caloric intake/day before the weight of the conceptus decreases?

1500 cal/day

T or F.  If you are a fetus of a rather large size, your chorionic villi surface area will be inceased proportionally?

True

Is the neonate more sensitive to increased pCO₂ or decreased pO₂?

pCO₂

How does the neonate change his/her minutes ventilation?

Increases the frequency of respiration

What percentage of the combined ventricular output does the placenta normally receive?

40%

What happens to this % after birth?

The lungs get it.

Why is fetal myocardial activity, as far as cardiac output goes, limited?

Aortic and pulmonary arterial pressures are equal

Within how many hours after birth does the ductus arteriosus close?

10-15

The closure of the ductus arteriosus is influenced by what factor?

The increasing   pO₂

What happens to ventricular output after birth?

LVO - increases 2-3X      RVO - increases 1-2X

What are the 5 factors that contribute to the decrease in pulmonary vascular resistance?

1) lung expansion

2) clamping of cord

3) increased pO₂

4) decreased pCO₂

5) increased pH

When does the fetus experience the most rapid weight gain?

32-38 weeks gestation

What enables the neonate to make the adjustment from anaerobic met. to aerobic met.?

Increase in # of mitochondria

T or F. Neonate brain can utilize ketone bodies.

True

What is substituted for glucose as a metabolic feul in neonates?

Fat

T or F. One problem with babies who are hypoxic is that they can’t oxidize FFA to

maintain blood glucose.

True

What is one condition that you see neonatal hypoglycemia?

Maternal uncontrolled diabetes

What is the most important determinant of fetal blood temperature?

Maternal arterial blood temp.

Non-shivering thermogenesis occurs where?

In brown adipose tissue

What controls thermogenesis in brown adipose tissue?

Sympathetics; NE is neurotransmitter

Who’s thermoregulatory ability is greater, adults or neonates?

Adults.  Neonates capacity is ¼ that of the normal adult

What is the range of optimum body temperature in neonates?

36-37.8⁰C

What substance, through increase in cGMP, increases uterine blood flow?

NO

In the first trimester do the uterine cells undergo hyperplasia or hypertrophy?

Hyperplasia

Hyronephrosis of pregnancy is usually limited to which side, right or left?

Right.  Sigmoid protects the left.

What are the 3 signs of pre-eclampsia?

Hypertension, proteinuria, edema

What happens to maternal serum creatinine during pregnancy?

Decreases

What happens to creatinine clearance during pregnancy?

Increases (50% increase)

Why does it take more Ang II to get a pressor response in pregnancy?

Increase in vascular refractoriness.

What happens to plasma osmolality during pregnancy?

Decreases to about 290-280 mOsm/L

What heart sounds (S1,S2,S3, and S4) are normal in pregnancy?

S1, S2, and S3

Is ESV increased, decreased, or unchanged during pregnancy?

Unchanged

Is EDV increased, decreased, or unchanged during pregnancy?

Increased in both LV and RV

What change serves to protect the mother from post-partum hemorrhage?

Increase in BV and RBC volume.

What happens to pulse pressure during pregnancy?

Increases due to fall in diastolic BP>fall in systolic.

Why does pulmonary resid. Vol., expir. reserve, and funct. Resid. Cap. all decrease

during pregnancy?

The enlarged uterus compresses the thorax

What happens to pulmonary vital capacity during pregnancy?

unchanged

What changes contribute to the “breathlessness of pregnancy”?

increase in pO₂; decrease in pCO₂

Which of these four crosses the placenta, TRH, iodine, T₃, T₄?

TRH and iodine

What other things, besides the placenta, can produce hCG?

1) hydatidiform mole

2) choriocarcinoma

3) fetal tissue

hCG has identical a-subunits with what other 3 hormones?

FSH, LH, TSH

Therefore, we have to measure hCG by measuring which subunit?

b

What hormone serves to stimulate and maintain the corpus luteum?

HCG

What hormones does hCG stimulate the corpus luteum to produce?

Estrogen, progesterone, relaxin

T or F.  hCG may act on fetal testis to stimulate testosterone production thus leading to

early masculinization?

True

When is serum hCG levels at its highest level?

8-10 weeks

When can most take home kits detect pregnancy?

2 weeks after conception

When the hCG does not double every 2-4 days starting at 4-5 weeks gestation, what

concerns you?

Ectopic pregnancy

Lab returns hCG levels of > 200,000 mIU/ml, what concerns you?

Hydatidiform mole, choriocarcinoma

Which hormone is responsible for the “diabetogenic effect” of pregnancy?

Human placental lactogen (hPL)

Which placental hormone is highest in level at term?

hPL

hPL has a 96% sequence homology with which hormone?

Human GH

What is the main estrogen of pregnancy, E₂ or E₃? Of normal menses?

E₃ (estratriol); E₂

Why does the placenta require a C-19 precursor for estrogen synthesis?

Lacks 17a-hydroxylase

What is the main precursor in estradiol (E₂) synthesis?

Dehydroandrosterone sulfate (DS)

Where does the DS come from, and in what percentages?

50% maternal adrenal; 50% fetal adrenals

What is the main precursor in estriol (E₃) synthesis?

16-a-hydroxydehydroepiandrosterone - 16a-OH-DS

Where does the 16a-OH-DS come from and in what %?

90% fetal adrenal; 10% maternal liver & adrenal

What is the largest organ of the fetus?

Adrenal

If you had a placental aromatase deficiency, what would you expect?

1) virilization of mother & fetus

2) very tall affected males

What is the most common cause of ß placental estrogen?

ß LDL-cholesterol

What happens to the placental estrogens in fetal erythroblastosis?

Production increases

What three substances are used frwquently to predict fetal abnormalities?

E₃, aFP, hCG

What does the trophoblast need for progesterone synthesis?

LDL cholesterol

You have a fetal death.  What happens to the levels of progesterone and estrogen?

Estrogen  ß, Progesterone unchanged

Why is the progesterone level unchanged when fetal death occurs?

Unaffected because it doesn’t require fetal input.  90% of cholesterol comes from maternal plasma.

When can you perform ultrasound?                Any trimester

Chorionic villus sampling?                  Only in 1^st trimester (usually 10-12 weeks)

Maternal serum screening                              2^nd trimester (usually done at 16-18 weeks)

Amniocentesis?                                               2^nd or 3^rd trimester

Fetal Blood sampling?                        2^nd or 3^rd trimester

What is advanced maternal age?

> 35

a-fetoprotein is related to what other plasma protein?

Albumin, both encoded on chromosome 4

What is the most frequent serious fetal malformation in the US? 2^nd most common?

CHD, Neural Tube Defects

Why is it most effective to give folic acid before the woman is pregnant?

The neural tube closes at 3-4 weeks, and folic acid has been implicated in reducing the

requency in NTDs.

What causes the MSAFP screening to be normal, even if there is a NTD?

Skin covering the defect.

What is the most common reason for false + MSAFP results?

Underestimation of gest. Age

T or F. NTDs have been associated with maternal diabetes mellitus.

True

What other drugs have been implicated in an increased risk of NTDs?

1- carbamazepine

2- Valproic Acid

3- retinoic acid

In what normal condition would you expect a doubling of MSAFP?

Twin gestations

What is the “lemon sign” (scalloping of the frontal bones) indicative of?

NTD (also banana sign)

If you have…                                                                           then you have…

Ý AFAFP & Ý AchE                                                                 NTD

Ý AFAFP & ß AchE                                                                 some other fetal defect

Ý MSAFP, normal AFAFP, (-) AchE                                        most likely normal

What is the most sensitive marker for Downs syndrome?

HCG

What lab values do you expect in a Downs syndrome fetus?

ß MSAFP, ß E₃, Ý hCG

How is MSAFP measured?

In Multiples of the Mean (MOM)

What lab values do you expect in trisomy 18?

ß MSAFP, ß E₃, ß hCG

What is the earliest that amniocentesis can be performed?

12 weeks

What are some disadvantages of amniocentesis?

1) takes 14 days to complete routine tests, 2) if preg termination to occur, it’s more   complicated.

What is the “big scare” concerning chorionic villus sampling?

Limb reduction defects

T or F. You can test for NTDs with chorionic villus sampling?

False. Have to do MSS.

Which vessel in the fetus has the greatest O₂ saturation?

Umbilical vein

Which part of the IVC has the greatest 0₂ saturation due to streaming?

Left and Dorsal portion

Via which mechanism does the fetus increase its CO the most?

By increasing its HR

The fetal heart is most sensitive to preload or afterload?

Afterload

Which has the greatest influence on fetal HR, parasympathetic or sympathetics?         Parasympathetics

What is the vagal response from the stretch receptor input of increased BP?

Slowing of HR & ß CO

On FHR tracings, you notice that the HR is bradycardic.  What worries you?

The baby may be hypoxic and have HTN

What usually occurs first in response to fetal “distress” (hypoxia)?

Increase in catecholamines

The ductus arteriosus connects which two structures?

Pulm. A. and aorta

The crista dividens directs flow from what to what?

IVC to the Left Atrium

The crista interveniens directs flow from what to what?

SVC to the Right ventricle

Which has the greatest O₂ stauration…

The RA or the LA?                                                                  LA

The umbilical artery or the umbilical vein?                              Umbilical vein

IVC or the ductus venosus?                                                    Ductus venosus

Umbilical artery or ductus venosus?                                       Ductus venosus

Umbilical vein or ductus venosus?                                          About equal (UV)

Which ventricle receives the blood that will supply the brain and myocardium?

LV

Fetal or Adult…

Which has the greatest CO (ml/min/Kg basis)                                                fetus

Which has the greatest CO (ml/min basis)                                                     adult

Which operates at the top of the cardiac function curve?                               fetus

Which has the greatest pO₂ value (normally)                                                 adult

What are the 5 fetal responses to “distress” (hypoxemia)

1) increase in catecholamines

2) slowing of HR
3) increase in BP

4) redistribution of CO to heart, brain, adrenal

5) increase in angiotensin II and AVP

What is the AAP recommendation for length of exclusive breastfeeding?

6 months

T or F. Breast feeding decreases the risks of some forms of cancer?

True. (due to hypo-estogenic state)

What is the tail of Spence?

The portion of the breast that extends into the axilla

What germinal layer gives rise to the ducts of the breast?

Ectoderm

What are the ligaments called that connect the breast to the underlying pectoralis?    Ligaments of Cooper

2-6% of women have hypermastia.  What is it?

Accessory mammary glands

How many milk ducts does the normal nipple contains?

15-25

What kind of secretion takes place in the mammary glands?

Merocrine (protein) and apocrine (fat)

What is responsible for the proliferation of the parenchyma of the breast during the luteal phase?

Estrogen

What hormone is responsible for the initiation of milk secretion?

Progesterone falls and PRL remains high

Why does the fall in progesterone initiate milk secretion?

Progesterone is an inhibitor of lactose synthesis

The maintenance of lactation in Stage III of lactogenesis requires what?

Removal of milk

If a woman chooses not to breast feed, how long are Prolactin levels detectable?

14 days

What is the stimulation for Prolactin release?

Suckling

If a mother is playing with her infant and her shirt becomes wet, which hormone is

responsible?

oxytocin

What is the mechanism of oxytocin on the breast?

Causes myoepithelial cell contraction and thus ejection of milk.

What can inhibit the Milk Ejection Reflex?

Stress and alcohol

What is the rate limiting enzyme in Lactose synthesis?

a-lactalbumin (progesterone inhibits)

Which vitamin has to be supplemented at birth because it is not transferred in mother’s

milk?

Vit K

What gives colostrum its yellow color?

b-carotene

What is the #1 component of mature milk?

Water

What does lactoferrin do?

Inhibits growth of iron dependent GI bacteria; protective for newborn

If you were a baby, which do you think would be easier, breast or bottle?

Bottle

How many times will a normal newborn nurse per day?

8-12

T or F. A law of supply ad demand exists between mother and child?

True

What are some signs that a baby is getting enough milk per feeding?

1) 6-8 wet diapers/day

2) loose stools daily

3) regains birth weight at 2 weeks

4) growth charts

Is Hepatitis B a contraindication for breast-feeding?

No

As menopause approaches, what accounts for the decreased estrogen levels?

Lack of follicle develop.

Why do serum FSH levels increase more than LH as menopause approaches?

1) Decreased inhibin levels

2) increased resistance to follicle recruitment

What is the principle estrogen before menopause and where is it made?

Estradiol, ovary

What is the principle estrogen after menopause and where is it made?

Estrone, adipose tissue

What is the underlying cause in the difficulty of sleeping after menopause?

Low levels of free Tryptophan

What dose estrogen therapy do to help sleep quality?

1) reduces the sleep latency interval

2) increases time in REM sleep

What causes the hot flashes during menopause?

a-adrenergic neurotransmission due to loss of estrogen

T or F.  Estrogen supplementation is protective against MI?              True

T or F.  Estrogen acts to increase HDL and decrease LDL?              True

T or F. Estrogen decreases Triglyceride levels?                                 False

T or F.  Estrogen decreases lipoprotein A activity?                            True

T or F.  Estrogen increases the relaxing capacity of the arterial wall?            True

Liver    Ý HDL, ß LDL, ß Cholesterol, Ý TG, Ý Free cholesterol, ß Lipoprotein A

Arterial Wall     Ý relaxing capability

Estrogen

Growth Factors

Heart   Ý Coronary Blood Flow

Ý Arterial Pulsality Index                                 ionotropic effects

Ý Myocardial Contractility

In post-menopausal osteoporosis, what type of bone suffers the greatest loss?

Trabecular Bone

What does an increase in urinary N-telopeptide tell you?

Bone loss is occuring

Does estrogen prevent bone loss or stimulate bone formation, or both?

Both, with a predominance of born formation in the premenopausal age groups.

What are some side effects of estrogen replacement therapy?

1) endometrial hyperplasia & cancer

2) thromboembolism & stroke

3) HTN

4) Breast Cancer

5) gall bladder dysfunction

Why give progesterone with estrogen?

To decrease the risk of endometrial hyperplasia and cancer.

Will a woman, with a uterus, when on continuous estrogen-progesterone therapy experience bleeding?

20% experience bleeding, usually spotting.

How much Ca per day is needed by the post-menopausal woman?

1200 mg/day for Repro

1500 mg/day for Pharm

Gametogenesis- the process of meiosis and cytodifferentiation that converts germ cells into mature male and female gametes, spermatozoa and definitive oocytes respectively.

-        timing between sexes differs

-        diploid —–  haploid

-        2n —– 1n

First meiotic division- involves DNA replication and recombination and yields two haploid 2n daughter cells.

-        Primary oocyte or spermatocyte -  the 4n cell coming forth from the 2n replication

-        The first meiotic cell division produces two secondary spermatocytes in the male or a secondary oocyte and a first polar body in the female.

Prophase

-        the chromosomes condense into compact, double-stranded structures

-        in late stage, the double chromosomes of each homologous pair match up, centromere to centromere, to form a joint structure called a chiasma.

-        The chiasma allows for crossing-over which accounts for an increase in genetic variability.

• the primary oocyte enters a phase of meiotic arrest during the first meiotic prophase.

Metaphase

-        the four-stranded chaisma structures are organized on the equator of a spindle apparatus similar to the one that forms during mitosis.

Anaphase

-        one double-stranded chromosome of each homologous pair is distributed to each of the two daughter nuclei.

-        The centromeres of the chromosomes do not replicate, and therefore the two chromatids of each chromosome remain together; which makes the resulting nuclei haploid, but 2n.

-        They contain the same amount of DNA as the parent germ cell, but half the number of chromosomes.

Second meiotic division - the double-stranded chromosomes divide, yielding 4 haploid 1n daughter cells.

-        no DNA replication occurs in the 2^nd meiotic division

-        the 23 double-stranded chromosomes condense during the 2^nd meiotic prophase, and then line up during the 2^nd meiotic metaphase.

-        The chrosomal centromeres then replicate

-        During anaphase the double-stranded chromosomes pull apart into 2 single stranded chromosomes and one is delivered to each daughter nucleus.

-        the 2^nd meiotic division produces two definitive spermatocytes or spermatids in males and in females it produces one large definitive oocyte and another dimunitive polar body.  The first polar body may undergo the 2^nd meiotic division and produce a third polar body.

-        In the female, the oocyte enters another phase of meiotic arrest during the second meiotic metaphase before the replication of the centromeres.  Meiosis does not resume until the oocyte is fertilized.

Spermatogenesis

-        at puberty the testes begin to secrete increased amounts of testosterone.

-        Stimulates the development of many secondary sex characteristics

-        triggers the growth of the testis

-        triggers the maturation of the seminiferous tubules

-        triggers spermatogenesis

Spermatgenesis

-        cells to undergo spermatogenesis arise from the spermatogonia via mitosis

-        these cells are gradually translocated between the Sertoli cells from the basal to the luminal side of the seminiferous epithelium while spermatogenesis takes place.

-        During this migratory phase, the primary spermatocytes pass without interruption through both meiotic division resulting in the four spermatids.

-        The spermatids undergo the changes that converts them into mature sperm while they complete their migration to the lumen of the seminiferous epithelium.

Sertoli cells

-        maturing spermatocytes and spermatids are connected to the Sertoli cells by tight junctions, gap junctions, and by a specialized junction termed  tubulobulbar complexes.

-        Tubulobulbar complexes- extend into the Sertoli cells; thought to provide a mechanism by which the excess cytoplasm is transferred to the Sertoli cells.

-        As the cytoplasm is removed, the spermatids undergo the changes that convert them into spermatozoa.

-        Finally the junctions with the Sertoli cells break, thus releasing the spermatozoa into the tubule lumen. (termed spermiation)

Spermatozoa

-        head- contains the nucleus and is capped by an apical vesicle (acrosome) filled with hydrolytic enzymes.

-        Midpiece- contains large, helical mitochondria and generates the power needed for swimming

-        Tail- contains the microtubules that form the propulsion system.

-        Errors are not at all uncommon

Spermatogenesis is continuous from puberty until death

-        gamates are produced in synchronous waves in each local area of the germinal epithelium

-        about four waves of synchronously differentiating cells can be observed in any given region of human tubule epithelium at any given time.

In the human male, each cycle of spermatogenesis takes about 64 days.

-        spermatogonial mitosis- 16 days

-        first meiotic cell division- 8 days

-        second meiotic cell division- 16 days

-        spermiogenesis- 24 days

·         Sperm produced in the seminiferous tubules are stored in the epididymis, which is a special duct connected to the vas deferens.

• During ejaculation, the sperm are propelled through the vas deferens and the urethra and are mixed with nourishing fluid consisting of secretions from the seminal vesicles, prostate, and bulbourethral glands.
• As many as 200 million spermatozoa are ejaculated
• Only a few humdred succeed in reaching the ampulla.

Capacitation

-        Capacitation- terminal step of functional maturation that prepares a spermatozoa to fertilize an oocyte; consists primarily of changes in the acrosome that prepare it to release the enzymes necessary to penetrate the zona pellucida of the oocyte;  thought to take place in the female genital tract and to require contact with the secretions of the oviduct.

Oogenesis

• the total number of primary oocytes is produced in the ovaries by the fifth month of fetal life.
• Germinal vesicle - thought to protect the DNA during the long period of meiotic arrest.
• Follicle cells- surround the primary oocyte in a single, squamous layer; oocyte and follicle cells together are termed primordial follicle.

Menarche- (Female puberty)

-        Menstrual cycle- responsible for producing monthly a single female gamate and a properly conditioned uterus to receive a fertilized embyro.

-        Monthly maturation of primordial follicle

-        Concurrent proliferation of the uterine endometrium

-        Ovulation

-        Continued development of the follicle into an endocrine corpus leutem

-        Without fertilization, the sloughing of the endometrium and the involution of the corpus leutem

-        28 days

• begins with menstruation (1-5)
• day 5- the hypothalmus releases gonadotropin-releasing hormone (GnRH) which stimulates to pituitary gland to increase secretions of two gonadotropins—-follicle stimulating hormone (FSH) and luteinizing hormone (LH)
• prior to the inc. secretions of the gonadotropins the primordial follicles thicken from squamous to cuboidal and are then termed primary follicles.
• The follicle cells and the oocyte together secrete a small amount of glycoprotein onto the surface of the oocyte which forms the zona pellucida. The epithelium of 5 to 12 of these primary follicles then proliferates to form a multi-layered capsule around the oocytes and are now termed growing follicles. Some continue to grow in response to the increased FSH, while others degenerate.
• Those that continue to grow take up fluid and form a central fluid-filled cavity called the antrum. These follicles are now termed antral or vesicular follicles.
• At the same time the connective tissue of the ovarian stroma surrounding each of these vesicular or antral follicles differentiates into two layers, the inner layer is called the theca interna and the outer layer is called the theca externa. These two layers become vascularized and the follicle cells do not.
• A SINGLE FOLLICLE CELL BECOMES DOMINANT AND THE REST DEGENERATE
• The dominant follicle cell continues to absorb fluid.
• Cumulus oopherous- the small mass of follicle cells surrounding the oocyte
• large swollen vesicle is now termed the mature vesicular follicle or mature graafian follicle; still has not resumed meiosis.
• Resumption of meiosis and ovulation are stimulated by an ovulatory surge in the levels of FSH and LH
• Day 13 or 14- the levels of LH and FSH rise very sharply (ovulatory surge)

-        stimulates the primary oocyte to resume meiosis

-        the cumulus oopherous expands in response to the ovulatory surge in LH and FSH

Ovulation

-        depends on the breakdown of the follicle wall

-        similar to an inflammation response

-        initiated by the secretion of histamine and prostaglandins

-        within a few hour of the ovulatory surge of LH and FSH, the follicle becomes more vascularized and becomes increasingly pink.

-        The follicle is then displace to the surface of the ovary, where it forms a bulge.

-        As ovulation approaches, the projecting wall of the follicle begins to thin, resulting in the formation of a small, nipple-like protrusion called the stigma.

-        FINALLY, a combination of tension plus the release of collagen-degrading enzymes and other factors by fibroblasts in the region causes the follicle to rupture; NON-EXPLOSIVE.

-        The oocyte, accompanied by a large number of investing  cumulus cells bound in the hyaluronic acid matrix and by some follicular fluid, is SLOWLY extruded onto the surface of the ovary.

-        Ovulation occurs about 38 hours after the ovulatory surge of LH and FSH.

Endocrine corpus leutem-  the ruptured follicle forms this structure

-        the corpus leutem is an endocrine structure that secretes steroid hormones that maintain the uterine endometrium in a conditioned state.

-        If no implantation occurs within 14 days, it converts into a scarlike structure termed a corpus albicans.

Estrogens and Progesterone secreted by the follicle control the uterine events of the menstrual cycle.

At fertilization, the sperm nucleus enters the oocyte, the oocyte completes meiosis, and the pronuclei of the two mature gamates fuse. Fertilization is a complex interaction between sperm and oocyte. If viable sperm encounter an oocyte in the ampulla of the oviduct, they surround it and force their way through the cumulus mass.

When the spermatozoa reaches the tough zona pellucida surrounding the oocyte, it binds with a glycoprotein sperm receptor in the zona (ZP3) and then the acrosome is induced to release degenerative enzymes that allow penetration of the zona pellucida. After penetration, the cell membranes fuse, which causes thousands of cortical granules located just beneath the cell membranes to release into the perivitelline space between the oocyte and the zona pellucida. The substance release by the granules causes a chemical change in the zona pellucida which alters the sperm receptor molecules, thus causing an impenetrable zona, preventing polyspermy.

Fusion of the two membranes also causes the oocyte to complete the second meiotic metaphase and also goes rapidly through anaphase to produce another polar body.  The oocyte is now considered to be a definitive oocyte. The chromosomes of the oocyte and sperm are then respectively enclosed within the male and female pronuclei. The pronuclei then fuse with one another to produce the single, diploid, 2N nucleus of the fertilized zygote.  This is taken to be the Beginning or zero time of embryonic development.

First few days of embryonic development:

Within 24 hours a series of Cleavages begins that subdivides the zygote without increasing its size. The subdivisions in the zygote are called blastomeres.  We are still inside the zona. At 40 hours, the second division is complete which has produces four equal blastomeres.

3 days—- 6-12 cells;   4 days—- 16-32 cells

By the 32 cell stage, the embryo is termed the morula (from the Latin for mulberry)

The cells of the morula will give rise to the embryo proper and attached membranes, and also to the placenta and related structures.

At the  8 cell stage, the blastomeres begin to flatten, developing an inside-out polarity that maximizes cell-to-cell contact among the blastomeres at the center of the mass.

As differential adhesion develops, the outer surfaces of the cells become convex and the inner surfaces become concave.  This is termed compaction. This development of differential adhesion causes segregation of some of the blastomeres to the center of the morula and others to the outside.

There is now an inner cell mass and the outer cell mass. There is some exchange between the two groups, however the inner group generally gives rise to the embryo proper and is thus termed embryoblast, and the outer cell mass gives rise to the membranes of the placenta and is thus termed the trophoblast.

By 4 days, the morula begins to absorb fluid which collects between the cells.

Also tight junctions and gap junctions begin to develop between blastomeres, especially between those of the outer cell mass.  As a result of the tight junctions forming between cells of the outer cell mass, the fluid collects between the cells of the inner cell mass. As the hydrostatic pressure increases because of the increase in fluid, a large cavity called the blastocyst cavity forms. The embryoblast then form a compact mass at one side of this cavity, and the outer cells or trophoblast is organized into a thin single-layered epithelium. The embryo is now termed a blastocyst.   The side of the blastocyst containing the inner cell mass is termed the embryonic pole and the side containing the outer cell mass is termed the abembryonic pole.

Beginning of implantation:

by day 5 the blastocyst hatches from the zona pellucida through the use of enzymes.

After about 6.5 days the blastocyst becomes very tightly adherent to the uterine lining. The adjacent cells of the endometrial stroma respond to its presence and to the progesterone secreted by the corpus leutem by differentiating into metabolically active, secretory cells called decidual cells.  This response is called the decidual reaction.

The endometrial glands in the surrounding area also enlarge and become highly vascularized and edematous.  (Sort of like an inflammation reaction) The uterine lining is maintained in a favorable state and kept from sloughing partly by the increased secretion of progesterone.  (In the absence of an implanted embryo, the corpus luteum normally degenerates after about 13 days) If an embryo implants, the cells of the trophoblast produce the hormone human chorionic gonadotropin (hCG) which supports the corpus luteum and thus maintains the supply of progesterone (Maternal recognition  of  pregnancy).

Ectopic Pregnancies

When a blastocyst implants in the peritoneal cavity, on the surface of the ovary, within the oviduct, or at an abnormal site of the uterus.

Symptoms:

abdominal pain

vaginal bleeding

Surgical intervention required

Applications to clinical practice:

Down Syndrome - trisomy-21; results from nondisjuncton

Amniocentesis- removal and examination of sloughed off cells contained in the amniotic fluid to determine karyotype

Turner syndrome- XO

Kleinfelter syndrome- XXY

Birth control methods

barrier contraceptives

birth control pills

depot preparations

nonmedicated intrauterine devices

RU-486

Sterilization

Assisted reproduction

in vitro fertilization and embryo transfer

gamate intrafallopian transfer

1)     Engagement - Bi-parietal diameter (BPD) descends through the plane of the pelvic inlet.

2)     Descent

3)     Flexion - chin tuck to decrease the diameter passing through the pelvis

4)     Internal Rotation - rotates past the spines

5)     Extension - keep occiput in contact with the pubic arch

6)     External Rotation - will turn same way as internal rotation to line up shoulders in AP diameter

7)     Expulsion

4 Signs of Placental Separation

1)     gush of blood

2)     lengthing of cord

3)     uterus rises in the abdomen

4)     uterus becomes firm and globular

Remember, don’t tug on the cord when the uterus is relaxed.

Treatments for the Neuropsychiatric disorders associated with AIDS:

Mild Neuro-cognitive disorder

• No confabulation

• Difficulty concentrating, unusual fatigue, subjectively slowed down, difficulty in remembering, learning and recalling new info

• Difficulty problem solving, abstract reasoning, and slowin of simple motor performances (finger tapping)

• Be sure to distinguish from delirium and dementia (these have confabulation)

Psychopharmacology - in addition to their usual HIV meds, stimulants (ie, methylphenidate) could be used - BE CAREFUL with drug interactions (CYP 3A4 & CYP 2D6)

HIV Associated Dementia - Signs and Sx

• The cognitive abnormalities in a person with dementia are more profound and more generalized than in persons with mild neuro-cognitive disorder

• Marked mental slowness and deterioration

• With disease progression, pt becomes more apathetic, severely disoriented, and frankly confused

• Slow onset, long lasting

• Difficulty in ADL’s

• Increased irritability, mood lability, delirium, paranoid ideations, auditory and visual hallucinations

- Neuroradiological exam - cortical atrophy (sulci dilation); EEG shows diffuse slowing

- Lab findings - low CD4, increased CSF neopterin and increased CSF quinolinic acid (proteins); ↑ CSF viral load correlated to severity of the dementia

- Course and Prognosis - about 50% of patients diagnosed with AIDS have either asymptomatic neuropsych impairment or mild neurocognitive disorder; poor prognosis

- Treatment

SSRI’s

• Cytalopram (Celexa)

• Escitalopram (Lexapro)

• Paxil (Buroxitine)

• Venlafaxine (Effexor) - good but be careful with the side effects

• Mood Stabilizers

• Valproic acid, and Gabapentin ( NOT Lithium!!)

• Anti-psychotics

• NOT low potency anti-psychs or Clozapine

• Benzodiazepine

• • • Esp. short acting or ultrashort acting

• • • No TCA’s or buproprion (↓ metab can cause toxicity)

• DO NOT USE Sertraline (↑ GI probs), FLuoxetine (can cause serotonin syndrome and has ↑↑ drug interactions CYP 2D6);

• Substance use - use of a substance in a socially acceptable manner (ie glass of wine at dinner)
• Drug misuse - doc using drugs not for medical use (prescribing drugs w.out seeing pts at a $50 charge)
• Abuse - a maladaptive pattern related to a drug you are using leading to clinically significant impairment or distress as manifested by one or more of the following occuring at any time during the same 12-mo period:

1. Recurrent substant abuse resulting in a failure to fulfill major role obligations at work, school, or home

2. Recurrent substance abuse in situations in which it is physically hazardous - your life or the life of others (ie “I can drive”)

3. Recurrent substance-related legal problems (DWI, PI, etc.)

4. Continued substance use despite having persistent or recurrent social or intepersonal problems

The DSM-IV diagnostic criteria for abuse require evidence of repeated occurences within a 12 month period of possible social, legal, or interpersonal trouble related to the substance.

I. Dependence

• aka “habituation” or “compulsive use”

• Psychological dependence- “I need whisky to speak in front of a crowd” or “I need X medication to sleep at night”

• Tolerance

Metabolic tolerance- liver metabolizes the drug quicker

Pharmacodynamic tolerance- adaptation of cells to drugs

Behavioral tolerance- don’t get the same behavioral response after prolonged use

1. Start drinking - lose inhibitions

2. Continue drinking for a year - need twice the alcohol to lose inhibitions

• Withdrawal or an abstinence syndrome is the appearance of physiological symptoms when the drug is stopped too quickly; usually the manifestations are opposite those of the drug

Ex. Cocaine euphoria, no sleep, no eat, ↑ sex; withdrawal ↑sleeping, eating,

depression, and ↓ sex

• Like tolerance, withdrawal is not an all or none phenomenon and usually consists of a syndrome comprising a wide variety of possbile symptoms, with patterns that are different for opiods, depressants, and stimulants

II. Factors that influence recreational drug use and patterns of use

Factors:

1. The physical reward potential

Feel like you have ↑ power (cowboys losing and the player walks on his broken ankle

Boxer is a young guy with many fractures but keep fighting and tolerate the pain

2. Peer pressure

3. Pleasurable effects

4. Social-learning component of drug use

You drink for the first time and throw up all night; your friends tell you that next time they will teach you how to drink.

5. Individual expectations as a component of drug use

Effects the indiv expects to gain from using the drug (relaxing from pot or halucinations from hallucinogenic drugs)

If they are getting the desired effects they will keep taking it

6. Family dysfunction (emotional, neglect, physical, and sexual abuse) leads to

unhealthy coping mechanisms

Patterns of Use:

- Regular daily intake of large amounts

- Regular heavy drinking limited to weekends- pt goes straight to drinking every fri

- Long periods of sobriety followed by drinking binges

III. Alcohol dependence

Primary vs. Secondary alcoholism

70% are primary (people without psychiatric problems to complicate the drinking prob)

30% are secondary (↑ anti-social personality, personality d/o, and MOOD d/o **TQ**

15-20% of female alcoholics and 5% of males have shown primary mood disorders and secondary alcoholsim

20% of male alcoholics and 5% of female alcoholics have shown anti-social personality disorders and secondary alcoholism; the opposite for females

Less than 10% of alcoholics demonstrate schizophrenia or other psychiatric disorder (Brisque’s hysteria) and anxiety disorders

There are an estimated 16 million people who are diagnosed as alcoholics

Prevalence of Alcohol dependance

• The prevalence of drinking is higher and abstention is lowest in the 21-34 year old range

• From 5-13% of the adult population in the USA will demonstrate alcoholism at some time in their lives

• It is important to recognize that alcoholism is a problem of all ages, all religions, all countries, and both sexes

• Higher rates of alcoholism are associated with….

1. Armed services

2. Lower socioeconomic strata

3. Lower income and education

4. Among Catholics

5. Among French and Irish

** don’t believe this 100%**

IV. Etiology

1. Psychological Theories

2. Pleasure theory- you feel great, powerful, euphoric

3. Defense mechanisms

- Denial- I am just a social drinker

- Projections- my wife brought me here but I don’t know why. Why didn’t she brin gher father…he drinks like a fish

- Rationalization - Yes, I drink, but I have to in order to survive at my stressful job

- Fragmentation - Form of denial. I am not an alcoholic…I have been sober for a week

- Minimization- I drink only a couple of drinks (means ½ bottle of whisky and ½ bourbon / night

V. Sociocultural theory - “you are probably an alcoholic because you have not been properly introduced to drinking (ex. Jewish are formally introduced to alcohol, but the Ashkenazies drink less)

• Biological Theory

- Acetaldehyde forms condensation products with biogenic amines

- Acetaldehyde + NE = TIQ (tetrahydroisoquinoline)

- Acetaldehyde + Dopamine = THP (tetrahydropapaveroline)

- Acvetaldehyde + 5HT = tetrahydro-beta-carbolines

• The TIQ Hypothesis

- Suggests that chronic alcohol use significantly reduces the brain’s production of the endorphins, the enkephalins, and the dynorphins

- TIQ was capable of binding opiate-like receptor sites within the brain’s pleasure center causing the individual to experience a sense of well-being

- TIQ’s effects were thought to be short-lived, forcing the individual to drink more alcohol in order to regain or maintain the initial feeling of euphoria achieved through the use of alcohol

VI. Genetic Factors

- Alcoholism runs in families

- On average about 40% of alcoholics have an alcoholic parent

- 2/3 of the studies reviewed, at least 25% probands have fathers who were alcoholics

- As many as 62% of one set of alcoholics had 1 or more relatives in the preceding 2 generations who had “problems with alcohol”

- Women seem to be more vulnerable than men to the impact of familial alcoholism

- Alcoholism was found more frequently than any other forms of mental illness in relatives of alcoholics

Adoption Studies

Characteristics:

- Recurrent multiple complaints that are not fully explained by the physical factors and that result in medical attention or physical impairment

- Chronic (↑ history)

- Before age 30

- Associated with significant psychological stress

- Aka “Briquets syndrome”

• Epidemiology:

- Women > Men

- Pts of the family doctor

- Begins before age 30 and most often in their teens

- 2/3 of the pts have other psychiatric symptoms

- Commonly associated with personality traits or disorders such as:

Avoidant

Paranoid

Self-defeating

Rigid

- ↑ risk for Bipolar I and substance abuse

• Etiology UNKNOWN

• Biological Factors - faulty perception of somatosensory inputs due to attention and cognitive impairment

• Genetic - runs in families, esp 1^st degree relatives

DSM-IV Criteria :

1. A history of many physical complaints before age 30 that can occur over a period of several years and result in treatment being sought or significant impairment in social, occupational, or other important areas of functioning

2. Each of the following criteria must be met with individual symptoms occurring at any time during the course of the disturbance

Four pain symptoms - history of pain related to at least four different sites or functions (head, abdomen, back, joints, extremities, chest, rectum, during menstruation/sex/urination)

Two GI symptoms- history of at least 2 GI symptoms other than pain (nausea, bloating, vomiting other than during pregnancy, diarrhea, or intolerance to certain foods)

One sexual symptom- other than pain (sexual indifference, erectile/ejaculatory dysfunction, irregular menses, excessive bleeding, vomiting throughout pregnancy)

One pseudoneurological symptom- one symptom or deficit suggesting a neurological condition not limited to pain. (conversion symptoms such as impaired coordination or balance, paralysis or localized weakness, difficulty swallowing, etc.)

3. Either a or b

a. after appropriate investigation, each of the symptoms in criterion B cannot fully be explained by known general medicine- condition or direct effects of a substance

b. when there is related general medicine condition, the physical complaints or resulting social or occupational impairment are in excess of what would be expected from history, PE or labs

4. Sx are not intentionally feigned or produced

5. Differential

Features useful in discriminating between somatization disorder and physical illness

involvement of multiple organ systems

early onset and chronic course without development of physical signs

absence of characteristic lab abnormalities

Somatization d/o pts have more guilt, suicide, self-deprecation, confused thinking, etc.

Physical d/o:

MS, SLE, AIP (acute intermittent porphyria), hyperparathyroidism, myasthenia g, AIDS, chronic systemic infections

Psychiatric d/o

Major depression, generalized anxiety, schizophrenia, hypochondriasis, conversion d/o, and pain d/o

***Serious debilitating condition!!!!!! Complications include divorce, suicidal attempts, ↑↑ surgical operations, drug dependence, etc.

• Treatment

Establish a therapeutic alliance w/ pt

Educate pts regarding manifestations of somatization disorder

Provide consistent reassurance

Anti-depressents, anti-anxiety agents (sometimes)

Treated by single doc

Psychotherapy

Conversion Disorder characterized by the presence of one or more neurological

symptoms that can not be explained by a known neurological or medical disorder

*Diagnosis requires that psychological factors be associated with that initiation or exacerbation of symptoms

• Etiology people exposed to ↑↑ trauma (esp child abuse)

- Conversion of psychological conflict into a somatic symptom

- 1/3 with Hx of sexual abuse, esp incestuous

- youngest or youngest of sex in sib order

- more frequent in relatives of individuals with conversion disorder

- Female relatives >> Male relatives (2:1)

• Clinical Features

- Sensory symptoms- anesthesia, paresthesia, deafness, blindeness, tunnel vision

- Motor symptoms- abnormal movements and gait disturbances (atasia-abasia), weakenss, paralysis, tremors, jerks

- Seizures

- Primary gain- anxiety is theoretically reduced by keeping an internal conflict or need out of awareness by symbolic expression of an unconscious wish as a conversion symptom

- Secondary gain - conversion symptoms allow avoidance of noxious activities or obtaining of otherwise unattainable support

Ex. I have a test today, but I don’t feel well so I think I will call in sick

- La belle indifference- severe acute onset of symptoms but the pt is indifferent or passive

- Identification- symptoms manifest themselves when the pt has found someone with an illness they can identify with

Ex. Hubby with right arm paralysis died 1 yr ago and the wife feels guilty and she now has right sided paralysis

• Differential

Neurological illness on follow-up

Physical illness and conversion are not mutually exclusive

Most reliable predictor of history is a previous conversion d/o

First occurring in middle age should increase suspicion

Neurological/Physical Medical d/o

MS - consider blindness secondary to optic neuritis w/ initially normal fundi

Guillan-Barre ( weakness in arms and legs may be inconsistent)

Myasthena gravis

eriodic paralysis

Myoglobinuric myopathy

Polymyositis

Other acquired myopathies

Hallucinations and pseudohallucinations

Non-psychiatric medical d/o

Somatization, hypochondriasis, pain, Malingering and Factitious disorders

• Course and Prognosis

- Onset is generally from late childhood to early adulthood

- Generally acute

- Self-limited

- Good prognosis- acute onset withpresence of clearly identifiable stress at the time of onset; shot interval b/t onset and treatment, no comorbid psychiatric condition, no ongoing litigation, and good intelligence

- Poorer prognosis- seizures and tremor

• Treatment

- Direct confrontation is not recommended

Hypochondriasis NOT preoccupation with symptoms themselves, but fear of having a serious disease based on misinterpretation of bodily signals

• Epidemiology- Men and women; 20-30 yrs old

• Etiology- aggressive and hostile; these can be transferred into complaints

• Differential - AIDS, endocrinopathies, myasthenia gravis, multiple sclerosis, SLE, occult neoplastic disorders, degenerative diseases of the nervous system

• Course and Prognosis- 66% show a chronic fluctuating course; usually episodic; episodes can be months or years and are separated by long quiescent periods and are usually associated with stressors

• Good prognosis- high SES, treatment-responsive anxiety or depression, sudden onset, absence of personality disorders, no psych medical conditions

• Treatment- resistant to psychiatric treatments

Body Dysmorphic Disorder- preoccupation with a body defect or an exaggerated distortion of a minimal or minor defect and persists even after medical reassurances; must cause significant distress or be associated with impairment in the patients personal, social, or occupational life

• Clinical Description- imagined flaws of the face or head, including various defects in the hair (too much or too little), skin, shape of the face, or facial features ( usually preoccupied with the shoulders and above - places people can see)

• Overlap with depressive disorder and OCD

• Epidemiology

- 2 of pts seeking corrective cosmetic surgery

- Age of onset = 15-20 yrs

- Women > Men

- More common in the unmarried

• Etiology

- Mood disorders

- Schizophrenia

- OCD

- Social phobia

- Coexist with other mental disorders (Depression 90%, Anxiety disorders 70%)

• Differential Diagnosis

1. Anorexia nervosa, Schizophrenia, OCD

2. Gender identity disorder

3. Brain damage

4. Narcissistic personality disorder

5. Normal concern about one’s appearance

• Course and Prognosis

Gradual onset TQ!!!!

Onset may have 2 peaks

Chronic condition with waxing and waning of intensity, but rarely full remission

Multiple preoccupations are typical

Highly incapacitating

• Treatment

- Surgery, derm, or dental treatments are usually unsuccessful

- Behavior therapy and dynamic psychotherapy

- Pharmacotherapy = Neuroleptics (Pimozide) and Antidepressents (MAOI’s, SSRI’s)

- Clomipramine, fluoxetine are effective in reducing symptoms in about 50% of patients

- Treatment of anxiety and depression

Pain Disorder- the presence of pain in one or more sites that is not fully accounted for by a nonpsychiatric medical or neurological condition; accompanied by emotional distress and functional impairement and the disorder has a possible causal relation with psychological factor

- Long history of surgical and medical care

- Pain can be complicated by drug abuse

- Patients often deny other sources of emotional dysphoria

- Pain disorder can be a picture of somatization disorder, depressive disorders, and anxiety disorders

• Pain-stress cycle

- Attempts to correct and correct the cause of pain

- Increased dependency on medication, docs, and others

- Increased frustration and self-doubt

- Demoralization (sense of failure, decreased esteem, hopelessness, increased pain)

- Ineffective intervention

Epidemiology

MOST FREQUENT COMPLAINT IN MEDICAL PRACTICE

Low back pain has diabled an estimated 7 million people

Twice as frequent in women as in men

Peak ages of onset are in the 40-50 years

Gate control theory:

Serotonin is probably the main NT in the descending inhibitory pathway; Endorphin deficiency seems to correlate with the augmentation of incoming sensory stimuli; mechanism in the dorsal horn

Undifferentiated Somatoform Disorder

- Presence of one or more clinically significant medically unexplained somatic symptoms with a duration of 6 months or more that are not better accounted for by another mental disorder; impacts social fxn

VII. Somatoform Disorder NOS

- Somatoform symptoms that do not meet the criteria for any specific somatoform disorder - true residual category

- NO MINIMAL DURATION

VIII. As per the “Specified Disorders”

Parameters could not be expected to be uniform for a residual category such as somatoform disorder NOS because it represents a grouping of diverse disorders

The School-Aged Child - middle childhood (elementary school-age, 6-7 yrs); child is:

• Educable- high focus on education; easy to teach

• Pliable- easily influenced by the external environment

• Well-behaved

• Learns roles & roles of society- right/wrong and appropriate/inappropriate behavior

- Freud - latency stage; a time of relative stability, tranquility in development

o Child not very self-reflective- not much time spent analyzing or introspecting; thinking here and now

o Play & activity orientated - social play (same sex grps); psychosocial development in place; reflect feeling in their playing that they struggle with

- Erikson - “Industry vs. inferiority” - 1^o task is mastery of environment and growth; needs encouragement in their strengths; child is: willing to learn, curious, able to function in grps

o Time of intellectual & physical growth & mastery- help child to identify strengths

o Child who doesn’t succeed feels inferiority-

- Piaget - “Concrete operations”; cognitive development develop how you feel about the world; NO ABSTRACT THINKING

o Reversibility - can see relationship in different views, “I am your brother, she is my sister”

o Conservation- beakers same water amt even though different heights

o Numerical concepts - can start adding & subtracting

o Time

o Generalizes from one situation to another- apply knowledge in different situations

o Free from egocentrism - can consider other’s perspectives

- Other issues

o Developmental changes are uneven & lengthy, not sharp & clear-cut

Child inconsistent - external structure is important (consistent praise/punishment); limit testing continues; fears being overwhelmed; mature one day but not the next

Use new skills better on familiar rather than unfamiliar tasks; not innovative

Skills change is less obvious

o Doesn’t grasp abstract concepts

o Language development continues- expanding vocab, increase grammar complexity

o Greater attention to tasks- focus on “doing things right” and in the “right order”

o Ideas about death - hazy, concrete, may think it’s reversible until age 9

o Social & moral understanding - rule-bound, “all or none”; example of breaking dishes

Social development

- Focus shifts toward peers; socializing influences (from outside home) for parent & teachers, books, media

- Self concept based on relative standing in reference grp

o Fairly concrete- eagle vs turtle reading group; must be careful because kids overvalure ranking

- Friendships now based on preference, interests, gender, age - “best friend”

- Normative expectations for age & sex very important to self-esteem

o Powerful sanctions against deviance for boys - boys feel they need “boys things”

o Less so for girls

- Peer grp

o Organized into grps, excluded adults; “No grown-ups allowed”

o Play emphasizes learning, mastering new functions, trying out new roles, secrecy

o More aware of privacy

o Grp activities tend to have rules reflecting need for control & structure

o Secret clubs often formed (”No girls allowed”)

- Play

o Team sports

o Ritualistic games - jump rope, hopscotch (repetitive)

o Sophisticated pretend play - imaginary friend

o Hobbies, collections - another way to organize/categorize

- Psychological problems w/grp

o ADHD

o LD (around 3^rd grade) - learning disorder

o Anxiety d/os (overly shy, OCD) social phobia

o School avoidance

o Depressive d/os

Pre-adolescence - time of awareness & anticipation

- May become interested in adolescent peers

- Beginning to discuss maturation & sexual questions in peer grps- not related to level of knowledge

- Initial opposite sex interest

Adolescence - begins w/puberty & ends when independence has attained a reasonable degree of psychological congruence; multiple areas of development (physical/endocrine, social, psychological, etc)

- Freud - “Genital phase” - reawakening of sexual interest

o Sexual drives directed toward opposite sex peer- think about sex like an adult; experiment with close ones

o Development of love relationships- not sexual

o Need to relinquish parental ties

- Erikson - “Identity vs. identity diffusion” - establishing identity in several areas

o Sexual- identity development

o Social-including political & religious views- increased susceptibility to cults and exploitation

o Occupational

o ‘Trial identities’

• Essential ingredient in a good patient therapist relationship is built on genuine trust & interest

• Hundreds of types of psychotherapy; all have different theories to how changes in pt occur

I. Psychoanalysis

The classical long-term insight oriented therapy

Goal = identifying major personality changes by identifying and “working through” unconscious conflicts by free association, analysis of the transferance and resistences, and dream interpretation

It takes several hundred hours

Selection criteria for patients for psychoanalysis

- Primary oedipal conflict

- Internal conflict

- The ability to symptom relief through understanding

- Have to be psychologically minded

- Able to experience and observe strong effects without acting out

- Have supportive relationships available in both past and present

Topographical Model of the Mind- Freud- includes:

- Conscious (awareness)

- Preconcious (readily available to conscious)

- Unconcious- thoughts and feelings that can’t be conscious without overcoming strong resistances; gives rise to

Dreams

Paraprexes (Freudian slips)

Psychological symptoms

Symptoms of psychological illness = conflicts b/t unconscious drives and moral judgements you make; repressed in an effort to avoid the actual conflict

Structual Theory of the Mind

- Id - reservoir of unorganized, instinctual drives

- Ego- “executive organ”; the seat of logic and abstract thinking; mediator b/t the id and the superego, and the actual reality based environment

- Superego- conscience controlled of ideals internalized from parental figures

The role of the therapist in psychoanalysis is limited to timely interpretation of the patients assns; not as active as other types of therapy

Transferance- the patients feelings and behavior toward the analyst that are based on infantile wishes the patient has towards parents/parental figures

Countertransferance- the analysts reaction to the patient, based on his or her past experienced

Dream interpretation- the manifest content is what the dreamer reports; the latent contnet is the unconscious meaning of the dream after condensations, substitutions, and symbols have been analyzed

Psychanalysis is usually used in pt termed “neurotic” or pts with personality disorders

Relative contraindications for this type of therapy include an older age, low IQ, if their life situation cannot be modified, antisocial personality disorders (have to be able to relate to someone), if there are time constraints, psychotic disorders

An analyst should not treat friends/relatives b/c this interferes with interpretation

II. Psychotherapy

• Supportive Psychotherapy- the goal is to evaluate the pts current lifesituation and his/her strengths or weaknesses, and help the patient make whatever realistic changes that will allow him/her to be more functional

- Usually weekly for several wks or months

- Works very little with the unconscious and doesn’t attempt major personality changes

- Techniques used:

Reassurance

Suggestion

Ventilation

Abreaction

Environmental manipulation

- Good candidates for this therapy are pts with coping problems or serioous psychiatric illnesses like schizophrenia and bipolar

- Abreaction- the process in which a memory of a traumatic experience is released from repression and brought into consciousness-when able to express the affect associated with memory, the affect is discharged and the symptoms associated with it disappear

• Brief Psychotherapy- short-term therapies that are based on psychoanalytic concepts; more practical today in managed-care environment; pt must be motivated for change; there has to be circumscribed focus that is agreed upon and a termination date usually set in advance

- Usually about 20 sessions

• Interpersonal Psychotherapy- goal is to improve current interpersonal skills; selection critertia include outpatient, nonbipolar, nonpsychotic depressive disorders

- Usually lasts 12-16 wks, once a week

- Techniques include:

Reassurance

Clarification of felling states

Improvement on interpersonal communication

Testing perceptions

• Crisis intervention- deals with persons in the midst of crisis - rapidity is of the essence; there must be a joint understanding of the psychodynamics of the situation and an awareness of how they are responsible for the crisis; goal is to understand maladaptive rxns the pt uses to deal with crisis and how to avoid this in the future

• Group Psychotherapy- treatment in which carefully selected emotionally ill people are placed in a group guided by a trained therapist to help one another effect personality change; two main strengths when compared to individual therapy include opportunity for immediate feedback from patients peers and the opportunity for both the pt and the therapist to observe the pts psychological, emotional, and behavioral responses to a variety of persons, eliciting a variety of transferances

- Goal is to aleviate symptoms, to change the interpersonal relations, and to alter specific family-couple dynamics

- Selection varies based on type of group:

Homogenous groups tend to target specific disorders

Adolescents and pts with personality disorders may especially benefit

- Contraindications include substantial suicide risk, sadomasachist acting out

- Different types include:

Directive-supportive

Psychodynamic-interpersonal

Family and couple

- Duration can be weeks to year; time-limited to open ended

- Therapists role is primarily a fascilitative one; ideally ythe group members themselves are the source of cure and change

- Self-help groups are composed of persons who want to cope with a specific problem or life crisis; members provide education, suppoprt, and alleviate a sense of alienation that the other members may be feeling

- The groups emphasize cohesion

• Psychodrama- a method of group psychotherapy in which personality makeup, interpersonal relationships, conflict, and emotional problems are explored by means of special dramatic methods; include the protagonist, auxillary egos, and the director

• Family Therapy

- Family Systems Theory- a family behaves as if it were a unit with a particular homeostasis of relating that is maintained regardless of how maladaptive it is

- The goals of therapy are to recognize and acknowledge the often covert pattern of maintaining balance within a family and to help them understand the pattern’s meaning

- Family therapists generally believe that one member of the family has been labeled the “identified patient”; the goal of the therapist is to help the family understand that the identified pts symptoms are serving a crucial function in maintaining the families homeostasis

- Several types

Family Systems Therapy- functioning in families is impaired by relationships with family of origin; poor differentiation, anxiety, family projection process, and family triangulation; goal is differentiation of family members and modification of relationships by detriangulation and repairing cut-offs

Structural Theory- symptoms result from current structural family imbalance; malfunctioning hierarchical arrangement; boundaries; goals of therapy are to reorganize family structure; shift members relative positions to disrupt malfunctioning pattern and strengthen parental hierarchy

• Marital Therapy- form of psychotherapy designed to psychologically modify the interaction of 2 people who are in conflict with each other over one parameter or many parameters - social, emotional, sexual, economic

- Problems in communication are a prime indications for therapy- need to see each other realistically

- Contraindications include patients with severe forms of psychosis, one or both of the partners really want a divorce, or one spouse refuses to participate out of anxiety or fear

- Goals to alleviate emotional stress and disability while promoting the well-being of partners together and individually

• Biofeedback- provides information to a person regarding 1 or more physiological processes in an effort to enable the person to gain some voluntary control over bodily functions that normally operate outside of consciousness— headaches, pain, tachycardia, asthma, bruxism to name a few

- Can cause EMG, EEG, GSR

• Behavior Therapy- goal is to modify learned maladaptive behavior patterns that lead to pathological symptoms; the emphasis is on removing overt symptoms, without regard for the patients private experiences or inner conflicts

- Selection requirements = specific, well delineated, easily identifiable maladaptive behaviors (phobias, overeating, sexual dysfunction); psychophysiological disorder in which symptoms are affected by stress (asthma, pain)

- Duration- generally time-limited, specific behavior

- Techniques based on Learning Theory (operant and classical conditioning)

Relaxation training

Reinforcements (Positive) - If behavioral response is followed by a rewarding event, it tends to be strengthened and to occur more frequently than before the reward

Aversive Therapy- pt is given an unpleasant, aversive stimulus when behavior is undesirable. Used for alcohol abuse, paraphilias, impulsive behaviors

Flooding- based on the premise that escaping from an anxiety provoking environment experience reinforces anxiety through conditioning; keeping the person in the anxiety-provoking situation will cause the fear to subside

Participant modeling

Token economies

Systematic desensitization- based on the behavioral principle of counterconditioning, which states that a person can overcome maladaptive anxiety elicited by a situation or object by approaching the feared situation gradually and in a psychophysiological state that inhibits anxiety

The pt attains a state of complete relaxation and is then exposed to the stimulus that elicits the anxiety

The negative reaction of anxiety is then inhibited by the relaxed state, a process that is called reciprocal inhibition

This process consists of 3 steps:

1. Relaxation training

2. Hierarchy construction

3. Desensitization of the stimulus

Example of a hierarchy for dog phobia

Looking at a picture of a dog in a childs book

Cuddling a childs stuffed dog

Seeing a dog on a leash at 10 yds, 5 yds, passing by

Touching a dog behind a fence in a store

Looking at the neighbors spaniel in the arms of the owner

Touch it when it is quiet and held by the owner

Stroking it

Looking at an Alaskan dog

Watching span. jump on road when pt is indoors/windows closed

Watching the spaniel walk around the room

Feeding the spaniel a biscuit

The spaniel being held by the owner and then jumping on the ground etc. etc. etc. ending in…

Dogs fighting

Desensitization is done systematically by having the pet proceed through the list while in a deeply relaxed state from the least anxiety provoking to the most anxiety provoking

- Graded exposure is similar to systemic desensitization, except that relaxation is not involved and treatment is usually carried out in real life situations

- Implosion therapy- pt with situation-caused anxiety is directly exposed for a length of time to that situation (flooding) or in imagination (implosion)

- Operant Conditioning- subject is active and behaves in a way that produces a reward-learning occurs as a consequence of action

- Classical Conditioning- (Pavlov)- new behavioral patterns can be developed when a given stimulus known to generate a response is paired with a second stimulus (conditioned response); Food + Bell = salivation; Bell = Salivation

Involves…..

- UCR- unconditioned resp

- UCS- unconditioned stim

- CR- Conditioned response

- CS - Conditioned Stimulus

• Cognitive Therapy

- The goal is to identify and alter cognitive distortions that maintain symptoms; used primarily for dysthymic disorder, nonendogenous depressive disorders, anxiety disorders

- Time Limited to 15-25 sessions

- Technique includes 4 main processes:

1. Eliciting automatic thoughts (cognitive distortions)

2. Testing automatic thoughts

3. Identifying maladaptive assumptions

4. Testing the validity of maladaptive assumptions

- In Depressive Disorder, for example, pts have a negative view of self, experience, and future

- Patients with Panic Disorder have a catastrophic misinterpretation of bodily and mental experiences

• Hypnosis

- Defined as, “the state or condition in which a person responds to appropriate suggestions by experiencing alterations of perceptions, memory, or mood; essential feature is the subjective experiential change

- Indicated in treatment of obesity, substance abuse related disorders, and anxiety

- Contraindicated in psychotic pts, OCD pts, and pts who have difficulty when they feel out of control

(Atypical psychotic disorders)

• Schizophreniform disorder episodee less than 6 months; often a tentative diagnosis; identical to schizophrenia in Tx and Sx; duration 1-6 mo

- Good Prognosis - short prodrome, confusion is predominent during the active phase, good morbid functioning, intact affect

• Schizoaffective disorder  Mood d/o + Schizophrenia; must have 2 wks of symptoms of schizophrenia but no symptoms of mood d/o; then symptoms of depression, mania, or hypomania w/o manifestations of schizo

- Intermittent affective symptoms punctuating an Active Psychotic Phase

- Psychosis is the backdrop NO affective symptoms without psychosis

- DDx: Major Depression with psychotic features; mania with psychotic symptoms

- Prognosis is better than for schizo

• Delusional Disorder

- Delusion- fixed belief w/ inability to entertain the possibility that it is wrong

- Bizarre delusions are not possible: thought insertion, thought control, referential thinking- e.g. seen in schizophrenia

- Non-bizarre delusions are possible- being followed, poisoned, infected, distant love, disease, deception\

- Symptoms

Erotomaniac - delusion that a high status person is in love with you

Grandiose - delusion of inflated worth, power, knowledge, identity, deification

Jealous- delusion of sexual infidelity of a partner

Paranoid/Persecutory- delusion of being malevolently treated; legal complaints

Somatic - physical defect, disorder, disease

• Brief Reactive Psychosis - same symptoms as schizophrenia; duration (1day - 1 month); disappear spontaneously; not supposed to wait….treat immediately

There is no prodrome, mood change or related organic factor identified.

Precipitants:

• emotional
• incoherance/LOA

Fortunately a  full recovery is expected.

Symptoms:

• perplexity hallucinations
• turmoil delusions
• catatonia
• disorganized behavior
• affective shifts for few hours to one month

Shared Psychiatric Disorder (folie a deux) - psychosis develops during a long-term relationship with another person who has a similar psychotic syndrome before the onset of symptoms in the patient with the shared psychotic disorder. (i.e. 2 people who live (isolated) together for a long time and one develops delusions and the other accepts the delusions as fact)

• Folie imposee - imposing delusions on others
• Folie simultanee - 2 people have delusions at the same time but they do not exchange delusions
• Folie communiquee - 2 people who live together have different types of delusions and they exchange delusions
• i.e. Pinell believes he is the president of the US and his wife believes that she is the queen of England and they believe each other
• Folie induite - same as above but she believes him and he does not believe her so one person is getting the delusion from the other

Autoscopic Psychosis - visual hallucinations of all or part of the persons own body; you see yourself in black and white and the image makes the same gestures that you are making (associated with migraines)

Cotards syndrome - or “delire de negation” characterized by nihilistic delusions; illusions of negations; ie, “I have no brain” or “I don’t exist”

Amok- preoccupation, brooding, mild depression followed by wild rage, running about madly, attacking people or animals. After the attack the person feels exhausted, does not remember the attack, and often commits suicide

Koro- TQ - Occurs among people of southeast Asia and in some areas of China. Characterized by the delusion that the penis is shrinking and may disappear into the pelvis/abdomen and that the person will die

Piblokto - occurs among Eskimos. Pts are usually women. The attack is characterized by screaming, tearing off and detroying their clothing; imitating the cry of some animals or birds; the pt may throw themselves on the snow or run wildly; after the attack, the person may appear to be normal and usually has no memory of the episode

Wihtigo or Windigo - confined to the Cree, Ojibwa, and Salteaux Indians of North America. The person who suffers this problem believes that he is going to be transformed into a Wihtigo, a giant monster that eats human flesh

• Post-Partum Psychosis (mood d/o + delerium)

- Epidemiology

• Incidence 1 or 2 per 1,000 childbirths

• 50-60% have had their 1^st child

• 50% have a family history of mood disorders

• Rare cases affect the father (Couvade syndrome)

- Etiology

Apparently they are essentially an episode of mood disorder

Perhaps they are associated with hormonal changes (↑ esrogen upregulates dopamine receptors  metabolites from estrogen occupy the dopamine receptor  when levels of estrogens go ↓ they are hypersensitive to dopamine stimulation

A few instances are associated with perinatal events such as infections, drug intoxication, sudden fall in hormones concentration

- Psychological Causes

Stressful events; some mothers don’t want to become pregnant, feel unhappy in marriage by motherhood; marital discord

The less stress in the life of the pt, the less potential problems faced

- Clinical Features

Mean time to onset is 2 or 3 weeks but the psychosis may start a few days after the delivery

Patient begins complaining of fatigue, insomnia, and restlessness; pt appears to be tearful or labile. Later the pt may be suspicious, confused, incoherant, irrational with obsessive concern about the baby. Delusions in 50% and hallucinations in 25%. Complains about the inability to move, to stand, or walk. Delusions that the baby is dead; not loving the baby; wanting to harm the baby of to kill herself. 5% of pts commit suicide, 4% kill the baby. Cause of the episode is similar to that seen in patients with mood disorder

- Treatment

More synthetic estrogen

anti-maniac

anti-depressant

ECT

TQ: Anti-psychotic blocks the dopamine receptor  upregulation of dopamine receptors (↑ in #)  release of dopamine  ↑ quantity, ↓ dopamine activity  eliminate anti-psychotic  exacerbation of condition b/c rec no longer is blocked and are increased in #

TQ: Clozapine eliminates tarditive dyskinesia; BZ’s, Clozapine, and Vitamin E (Parkinson-like syndrome)

Definitions

• Hallucinations

• Delusions

• Thought disorder

• Impaired reality testing

Prevalence- not common among kids (1%); most present in young adulthood

Symptoms

1. Hallucinations- no sensory input

Organic, psychiatric, and medical conditions

Most common + Sx on schizophrenia (80% of childhood schizophrenia; AUDITORY is most common)

RARE/poorly formed before age 7

Different from and illusion because in an illusion there is sensory input- you see something but interpret it wrong

More ELABORATE in OLDER children

Adolescents similar to adults

Mood congruent

Can be associated with *depression, dissociative disorder, and conduct disorders

2. Delusions

Says, “the police are after me,” so ask how do you know?

Present in 60% of childhood schizophrenia

ncreasing complexity with age

Common in effective psychosis psychotic symptoms related to mood disorder

3. Thought Disorder

Difficult to screen fantasy from reality

Loose association (most common TD) and flight of ideas (seen in mania)

Transiently seen in dissociative disorders

May see in normal kids under age 7

Poverty of speech

Frequency unclear

Several forms

Rating scales are available

4. Affective Disturbances

Negative symptom

Flat affect is common

May see in

Depression

Anxiety

Antisocials

Borderlines

Premorbid Features

Social Withdrawal- if the child is timid before the diagnosis of the onset of schizophrenia then they have a worse prognosis

Poor school performance and peer relationships

Variable onset

- Insidious- gradual, starts as a little odd and gradually gets worse

- Acute- Normal  BOOM Psychotic

- Insidious with acute episode- Premorbid  BOOM  Psychotic

History of ADHD or a conduct disorder- it is unusual for ADHD to change to schizo

Neuro-developmental abnormalities- slowing, seizures

Etiology

• Biologic Factors

- Neurologic findings - soft neurological signs; mild; not enough to point towards a lesion

- EEG

- Family history- HIGH rate in parents of kids who have schizo that starts in childhoos

- Processing deficits and poor attention

- Genetic link

• Family Characteristics

- Communication patterns

- High expressed emotion- schizo kids have a very hard time with drama queens in the fam

• Environmental Factors

- Event may precipitate an episode

- Lower SES (”downward drift”)

Diagnostic Studies

• Biologic

- No biological marker

- Careful medical evaluation- H&P

• Psychological

- No assocoation with MR

- Look for learning disabilities to help with school placement

- Projective testing- non-specific stimulation; Roreschak test, drawing and interpreting, etc

Differential Diagnosis

• Schizophrenia

- Duration- + symptoms for at least 6 months

- Impairment- social/occupational failure; school work declines

- Rare in childhood (before puberty)

• Mood Disorders

- Easily confused with bipolar early on

- More common

- Premorbid function is better

- Flat affect may come later

- Stronger family history (including depression and substance abuse)

• Other Psychiatric Disorders

- Borderline personality- transient (cut on themselves, etc)

- Dissociative disorders- increased mood symptoms and inappropriate sexual behavior, irritability

- Autism- social isolation; no hallucinations and delusions

• Organic Conditions

- EEG/imaging

- Delerium- fluctuation in level of consciousness

- Seizure disorders- may have other CNS symptoms associated with it

- Intoxication- illegal drugs or cross-reactivity of another drug

Treatment

• Medication

- Typical neuroleptics (haldol)- problem: kids increase their susceptibility and tarditive diskinesia

- Newer agents- suggested so patients but over the counter

• Psychosocial

- Development- growth/social skills

- Family- Education

- Social Skills

- School - learning disability

Outcome

• Early onset is WORSE

• Good prognostic factors:

- Higher EQ

- Normal EEG

- Mood symptoms - bipolar > schizo

- Acute onset- better prognosis

- Family history of mood disorders

Terms

• Personality- enduring pattern of perceiving, relating to , & thinking about environment & self.  Exhibited in social and personal function.   Reflects personality traits.
• Character- person’s distinctive nature
• Temperament- biologically (genetically) based, simple, nonmotivated characteristics.  Become stable after first few years of life.  (ex. Quiet, shy, active)
• Personality disorder- chronic maladaptive pattern of behavior.  Unpredictable & egocyntonic (don’t care or can’t understand what their actions may cause) Usu. associated w/ social & occupational dysfunction.

Diagnostic criteria

A.     Marked deviation from cultural expectations.  At least 2 of the following:

1. Cognition- way of perceiving & interpreting self, others,  & events.
2. Affectivity- range, intensity, lability, & appropriateness of emotions.
3. Interpersonal functioning for impulse control.

B.     The pattern leads to chronic, significant distress/impairment in social, occupational, or other important areas of function.

C.    Pattern is stable & enduring.  Can be tracked back to adolescence or early adulthood.

D.    Pattern not better explained by a different disorder.

E.     Pattern not due to a substance (ex. drugs) or a general medical condition (ex. head trauma)

Significance

A.     Costly to society.  The following figures represent the % of the named population that have PD’s.

• Criminals- 70-85% (incl. murderers: infanticide, matricide (kill parents), filicide (kill offspring))
• Alcoholics- 60-70%
• Substance abusers- 70-90%

B.     Personality along with other psychiatric disorder (ex. Depression, panic, OCD) usually doesn’t respond well to meds.

Classification

Cluster A (odd, eccentric)

1)   Paranoid

1. characteristics- suspiciousness
2. epidemiology- 0.5-2.5% of pop.  More in men.
3. Etiology- genetic…common if related to schizophrenic or someone w/ delusional DO. -psychodynamics…Erikson’s trust v. mistrust.  Defense mech. …projection.
4. Dx- suspicious, preoccupied w/ doubts, reluctant to confide, finds hidden motives, unforgiving, critical, sensitive to criticism, pathological jealousy.
5. Diff.- Paranoid schizophrenia, delusional DO, psychotic DO, schizotypal personality DO, borderline personality DO.
6. Px- early adulthood onset, chronic, poor Px w/out therapy.
7. Tx- psychotherapy, antipsychotics, anxiolytics.

2)   Schizotypal

1. characteristics- social & interpersonal deficit, cognitive/perceptual distortions, eccentric behavior.
2. Epidemiology- 3-5% of pop.  More in men.
3. Etiology-       genetic…common if 1^st deg. relative of schizophrenic.  More in monozygotes than dizygotes.

-        psychodynamic…DMs… fantasy, regression, projection

-        biologic… abnl. biogenic amines & structural abnormalities like schizophrenia

1. Dx- odd beliefs, magical thinking, ideas of reference, perceptual disturbances (ex. Illusions, odd speech, paranoid ideation), inappropriate/constricted affect,  weird behavior/appearance, lack of friends.
2. Diff.- schizophrenia, psychotic DO, delusional DO, major depression w/ some psychosis thrown in, schizoid personality DO, paranoid personality DO.
3. Px- early adult onset, chronic, severe social impairment, poor Px.  10-20% of Pts develop full schizophrenia.
4. Tx- antipsychotics, antidepressants, anxiolytics, psychotherapy.

3)     Schizoid

1. characteristics- detachment, restricted emotions, loner, cold person.
2. Epidemiology- 0.5-7% of pop.  More in men.
3. Etiology-   genetic…common if relatives have (-) symptoms of schizophrenia

-        psychodynamic…traumatic early experience.   DMs…fantasy, repression, regression.

1. Dx- loner.  No desire for relationships, sex, pleasure, praise.  Cold, flat affect.
2. Diff.- schizophrenia, major depression, anxiety DO, schizotypal, avoidant, OCD.
3. Px- early adult onset, chronic.
4. Tx- psychotherapy, antipsychotics, antidepressants, anxiolytics.

Cluster B (dramatic, erratic)

1)     Borderline

1. characteristics- instability of relationships, self-image, affect, & impulses.
2. Epidemiology- 2-3% of pop.  More in women.
3. Etiology-   genetic… common if a 1^st deg. relative has mood DO (ex. Major depression)

-        Psychodynamic… fixated in Mahler’s separation individuation phase.  Poor object constancy.  DMs… splitting, projection, idealization, devaluation.

1. Dx- fear of abandonment, unstable emotions, relationships, identity,  and impulses (anger).  Suicidal, self-mutilative, chronic feelings of emptiness,  stress-related paranoia or dissociative symptoms.
2. Diff.- Schizophrenia, depression, bipolar DO, cyclothymia, dissociative DO, histrionic personality DO, antisocial PDO, paranoid PDO.
3. Px- adolescent onset, variable course, usually subsides in 30’s & 40’s.  Complicated by suicide and substance abuse.  8-10% of Pts die from suicide.
4. Tx- psychotherapy, antipsychotics, antidepressants, antimanics, anxiolytics.

2)     Antisocial

1. characteristics- disregard for and violation of the rights of others.
2. 2-3% of pop.  More in men.  More in low socioeconomic, urban pops.
3. Etiology-    genetic… higher monozygotic concordance.  Common if 1^st deg. relatives have depression, substance abuse, somatization DO.

-        psychodynamic… poor parenting, ADHD, conduct DO, illegitimate or adopted, big family (esp. w/ brothers), divorce, poor school situation.  DMs… regression, repression, aggression, acting out.

1. Dx- don’t follow rules/laws, liar, impulse problems, irritable, aggressive, reckless, irresponsible, remorseless.   At least 18 y.o.a.
2. Diff.- Mood DO (ex. Bipolar, depression), schizophrenia, borderline PDO, narcissistic PDO, histrionic PDO, paranoid PDO.
3. Px- onset before 15 y.o.a.  Often  subsides in 30’s & 40’s.  Complicated by substance abuse, depression, incarceration.
4. Tx- psychotherapy (self-help or group), substance abuse groups, antidepressants, methylphenidate (Ritalin), antimanics.

3)     Histrionic

1. characteristics- excessive emotions and attention-seeking behavior
2. epidemiology- 2-3% of pop.  More in women.
3. Etiology-   genetic… common w/ 1^st deg. relatives w/ same problem.

-        psychoanalytic… Freud’s phallic phase (should be 3-5 y.o.a.).   Dm’s… acting out, fantasy, dissociation, reaction formation.

1. Dx- must be enter of attention, seductive, shifting emotions, shallow, impressionistic speech, lacking in detail, self-dramatization, exaggeration, easy suggestibility.
2. Diff.- borderline PDO, antisocial, narcissistic PDO, mood DO (ex. Bipolar or manic), cyclothymia, somatization DO.
3. Px- early adult onset
4. Tx- psychotherapy, antidepressants, antimanics, anxiolytics.

4)     Narcissistic

1. Characteristics- grandiose, needs admiration, no empathy.
2. Epidemiology- <1% of pop.   More in men.
3. Etiology-   psychodynamic…parental grandiosity.  DMs…projection, repression.
4. Dx- self-important, fantasies of success, power, brilliance, beauty, love.  Wants excessive admiration/entitlement, takes advantage of others, no empathy, envious, and believes others are envious, arrogant.
5. Diff.- histrionic, antisocial, borderline, and paranoid PDOs.   Mood DO (ex. Bipolar), paranoid schizophrenia,  delusional DO.
6. Px- early adult onset.  Complicated by depression (esp. in mid-life), psychosis, suicide.  Occupational and social impairment.
7. Tx- psychotherapy, antipsychotics, antidepressants, anxiolytics, antimanics.

Cluster C  (anxious, timid)

1)     Obsessive-Compulsive

1. characteristics- orderliness, perfectionism, meticulousness, preoccupation w/ details, rules, lists, orders, and schedules.
2. Epidemiology- 1-2% of pop.  Men and women equally.
3. Etiology-    genetic… higher concordance in monozygotes.  Common if 1^st deg. relatives have same problem.

-        psychodynamics…Freud’s anal stage.  Erikson’s autonomy v. shame & doubt.  DMs… intellectualization, rationalization, reaction formation, isolation.

1. Dx- perfectionism, workaholic, overconscientious, inflexible, can’t throw stuff away, can’t delegate, miserly, rigid and stubborn.
2. Diff.- major depression, anxiety DO (generalized or social phobia), narcissistic, paranoid, antisocial, or passive aggressive PDOs.
3. Px- early adult onset
4. Tx- psychotherapy, antidepressants, anxiolytics

2)     Dependent

1. characteristics-  excessive need to be taken care of.  Submissive & clingy.  Fears separation.
2. epidemiology- unknown %.  More in women.
3. Etiology-   genetic… higher concordance in monozygotes.

-        psychoanalytic… Freud’s oral dependent stage.   DMs… regression, repression.

1. Dx- can’t make decisions, needs reassurance, can’t disagree, doesn’t initiate projects, wants nurture and support, fear of being alone, replaces relationships quickly.
2. Diff.- borderline, avoidant, & histrionic PDOs, depression, agoraphobia, social phobia.
3. Px- unknown
4. Tx- psychotherapy, antidepressants, anxiolytics.

3)     Avoidant

1. Characteristics- social discomfort, low self-esteem, hypersensitivity to criticism.
2. Epidemiology- 0.5-1% of pop.  Men and women equally.
3. Etiology-  psychodynamic… childhood/adolescent disfigurement or illness.  DMs… regression, repression, displacement, avoidance.
4. Dx- avoids interpersonal contact, reticent to get involved & resistant in relationships, preoccupies w/ criticism & rejection. Poor self-esteem.  Little risk-taking.
5. Diff.- Schizoid or narcissistic PDOs, anxiety DO, depression.
6. PX- unknown
7. Tx- psychotherapy, antidepressants, anxiolytics

General considerations about suicide

-        Contagious effect

Myths about suicide

-        People who talk of suicide don’t commit suicide

-        Suicide happens w/o warning

-        Suicidal persons are fully intent on dying

-        Once a person is suicidal, s/he is suicidal forever

-        Improvement following suicide crisis means risk of suicide is over

-        Suicide is inherited

-        Asking someone about suicide, suggests it

Statistics

-        Suicide account for 12% mortality in adolescent & young adult group

-        As many as 4% of high school students have made attempt within previous 12 mo

-        8% of high school students have made attempt sometime in their lifetime

-        As few as 1:8 of attempts by adolescents ever come to medical attention

Epidemiology

-        Background

o   Rate of adolescent suicide has tripled in past 3 decades

o   Relationship to EtOH abuse & depression

o   ­ availability of firearms

o   Family instability

o   Prevalence of suicidal behavior - no central registry

-        Age - completed suicide not a common in pre-pubertal kids

-        Sex

o   Female to male attempts 3-9:1

o   Completed suicide 3:1

-        Race of socioeconomic studies - whites at higher risk

-        Method of suicide

o   Firearms most common methods - use by women ­

o   Hanging, jumping, CO intoxication & self-poisoning

o   Suicide attempts

§  ODs

§  Wrist-cutting

-        Circumstances of suicide

o   Long-standing hx of problems (child & family)

o   Progressive failure of coping techniques

o   Failure of relatedness

-        Precipitants

o   Affective & antisocial symptomatology

o   Substance abuse hx

o   Previous threat or attempts

o   Hx of other difficulties - impulsivity, poor interpersonal, problem-solving & social skills

-        Family hx of psychiatric d/os

o   Unipolar or bipolar affective d/os

o   Antisocial d/o

o   Attempted suicide & completed suicide in parent

o   EtOH & substance abuse

-        Family environment

o   Marital breakdown - family discord & disruption

o   One-parent household

o   Frequent move

o   Parental absence & abuse - loss of parent (particularly before age 12)

-        Exposure to suicide

o   Family & peers

o   Media

-        Medical illness

o   Epilepsy

o   HIV infx?

Tx

-        Assess suicidality

o   Psychiatric risk factors

o   Poor social adjustment

o   Family/environment

-        After identification of suicidality (evaluation)

o   Non-judgmental interview

o   Psychiatric consultation

-        Management of suicide attempters

o   Assess suicidality/lethality

o   Psychiatric hospitalization

-        General psychiatric tx strategies

o   No-suicide contracts

o   Availability of 24-hr clinical back-up

o   Removal of firearms

Prevention of suicide

-        By non-psychiatric physicians - ask the question

-        In schools - 1^o prevention

-        After suicide has occurred

-        Hotlines & peer counseling

Conclusions

-        Serious public health problem

o   Contagious effect

o   ­ in general occurrence

Criteria for depression

Mood d/os occur in infants, children & adolescents; ds made by same criteria use to ds mood d/os in adults, w/ minor modifications that take into account different developmental levels observed in kids

-        Major depressive episode - represent a change from functioning; at least one of the symptoms is either 1) depressed mood or 2) loss of interest or pleasure

o   Depressed mood ® irritability

o   Markedly diminished interest or pleasure (anhedonia)

o   Physical symptoms

§  Significant wt loss or gain - failure to gain wt as should

§  Insomnia (classic) or hypersomnia nearly every day

• Terminal insomnia - wake early in morning & can’t go back to sleep
• Middle insomnia - waking in middle of night & has trouble falling back to sleep
• Initial insomnia - trouble falling asleep

§  Psychomotor agitation or retardation nearly every day

§  Fatigue or loss of energy nearly every day

§  Feelings of worthlessness or excessive/inappropriate guilt

§  Diminished ability to think or concentrate or indecisiveness nearly every day

§  Recurrent thoughts of death (not just fear of dying), suicidal ideation w/o specific plan, or suicide attempt or a specific plan for committing suicide

Etiology

-        Genetic model

o   Twin studies

§  Concordance for affective (mood) d/o in monozygotic twins = 76%, compared w/19% in dizygotic twins

§  When monozygotic twins are reared apart, concordance rate drops to 67%

o   Family studies

o   Adoption studies

-        Biochemical factors - NE & 5-HT (‘chemical imbalance’)

-        Role of environment - can trigger episode, especially in those predisposed

o   Loss or stress

o   Marital discord

o   Parental affective d/o

o   Neglect/abuse

-        Psychological factors

o   Psychodynamic model - ‘anger turned inward;’ failure in development

o   Life stress model - not predictive, but may be factor

o   Cognitive distortion model

§  “Bad things always happen to me, & they always will”

§  Assuming blame/guilt

§  Stuck in present (situation won’t ever change)

o   Learned helplessness model

Epidemiology

-        Reported prevalence of depression in kids varies widely

-        THE YOUNGER THE PT, THE LESS LIKELY THEY’LL BE DEPRESSED

o   Depression in preschoolers = 0.3%

o   Depression in pre-pubertal kids = 1.8%

o   Depression in 14-16 yr-olds = 4.7%

-        Clinic samples

o   Of kids attending psychiatric o/pt clinic = 28%

o   Of those evaluated in educational diagnostic center = 53%

o   Of general pediatric medical inpts = 7%

o   Of pediatric neurology inpts = 40%

Clinical presentation - developmental level & depressive symptoms

-        Infancy

o   Anaclitic depression

o   Failure to thrive (non-organic) - can be fatal

o   Caretaker problems & life events

§  Parental depression

§  Rejection

§  Abuse - neglect (physical & psychological)

-        Pre-school child (2-6 y) - looks very sad; limited verbal communication; appears “slowed down”

o   Symptoms

§  Severe separation anxieties (tantrums)

§  Hyperactivity

§  Somatization - ‘tummy aches’

§  Social withdrawal - weepiness

o   Caretaker problems & life events

§  Parental depression

§  Abuse/neglect

§  Separation - death, hospitalization, divorce

-        School-aged child - verbal repertoire makes them more accessible to be listened to & understood; can tell how they feel, but not good w/time

o   Symptoms

§  Depression similar to adult picture

§  School refusal or poor performance

§  Psychosomatic symptoms - headaches, abdominal pain

§  Aggression

§  Hyperactivity

§  Isolating behavior

§  Suicidal thoughts - 1^st grp to discuss

• Running into risk
• Jumping from high place
• Hanging themselves
  • Caretaker problems & life events

§  Caretaker depression

§  Abuse

§  Illness or death of parent

§  Parental discord or divorce

§  Chronic illness

-        Adolescence

o   Symptoms

§  Running away from home, truancy - impulsive behaviors

§  Drug or EtOH abuse - which came 1^st: depression or substance abuse

§  Anorexia - not anorexia nervosa - no distorted image

§  Psychosomatic symptoms - malaise, fatigue

o   Caretaker problems & life events

§  Parental depression

§  Parental divorce

§  Parent death

§  Peer death, especially suicide

§  Chronic illness

Differential ds

-        Pre-schooler - evaluate for organic “failure to thrive”

-        School-age child - ADHD, anxiety d/o - OCD

-        Adolescent - all organic causes that may precipitate affective-type symptoms should be considered & excluded, including substance & EtOH abuse; anorexia nervosa & other eating d/os; AIDS; bipolar d/o

o   Kids w/depression have ­ risk for developing bipolar d/o

Assessment & tx

-        Before initiating tx for depressed child, perform a complete physical exam & lab tests to rule out medical conditions that mimic depression

-        Psychotherapy

o   Cognitive therapy for teens

o   Play-type therapy for younger kids

-        Pharmacotherapy - tricyclic antidepressants

-        Focus on child’s environment

Prognosis

-        Pretty good for treating episode, but lifetime risk for recurrence is ­