First Aid USMLE Step 1: Behavioral Science and Psychiatry
Stages of Change in Overcoming Substance Addiction
1. Precontemplation: - not yet acknowledging there is a problem 2. Contemplation: - acknowledging there is a problem, but not yet ready or willing to make a change 3. Preparation/determination: - getting ready to change behaviors 4. Action/will power - changing behaviors 5. Maintenance - maintaining the behavior changes 6. Relapse - returning to old behaviors and abandoning new changes
Acute stress vs PTSD timing
Acute stress = lasts between 3 days and 1 month PSTD: lasts > 1 month
For the following diseases, please name the neurotransmitter changes observed: Alzheimers Anxiety Depression Huntington Disease Parkinson Disease Schizophrenia
Alzheimers: - decreased ACh - increased glutamate Anxiety: - increased norE - decreased GABA and 5HT Depression: - decreased norE - decreased 5HT and DA Huntington Disease: - decreased GABA, ACh - increased DA Parkinson Disease: - decreased DA - increased ACh Schizophrenia: - increased DA
What is capitation?
An arrangment in which a payor (individual, group, government) pays a *fixed, predetermined fee* to cover all the medical services required by a patient. Capitation is the payment structure underlying HMO (health maintenance organization) provider networks. Under this model, there is a incentive for the provider and patient to reduce expenses, by restricting patients to a limited panel of providers within the plan, requiring referrals from a primary care provider prior to specialist consultations and denying payment for services that do not meet evidence-based guidelines
Bipolar Disorder (manic depression) Type I Type II Cyclothymic Disorder
Bipolar Disorder (manic depression) Type I: presence of at least 1 manic episode +/- hypomanic or depressive episode Type II: presence of hypomanic and depressive episode RX: mood stabilizers (lithium, VPA, carbamazepine), atypical antipsychotics *Cyclothymic Disorder:* - milder form of BP type II lasting at least 2 years with fluctuation between mild depressive and hypomanic symptoms
For the following core ethical principles, define them: Autonomy Beneficence Nonmaleficence Justice
*Autonomy*: obligation to respect patients as individuals, create conditions necessary for autonomous choice (informed consent) and to honor their preference in accepting or not accepting medical care *Beneficence*: physicians have a special ethical (fiduciary) duty to act in the patients best interest. May conflict with autonomy (an informed patient has the right to decide). or what is best for society (ie: mandatory TB treatment). Traditionally, patients interest supersedes *Nonmaleficence*: - "DO NO HARM" - must be balanced against beneficence - if the benefits outweigh the risks, a patient may *Justice*: - to treat persons fairly and equitably - DOES not alway imply equally (ie: triage)
Delineate what a clinical trial is and the purpose of each of the 4 phases of a clinical trial:
*Delineate what a clinical trial is and the purpose of each of the 4 phases of a clinical trial:* - experimental study involving humans - compares therapeutic benefits of 2 or more treatments - study quality improved by randomization, controls and double-blinding - triple blind refers to additional blinding of the researchers blinding the data Phase I: - small # healthy volunteers - "is it safe?" - safety, toxicity, pharmacokinetics and pharmacodynamics Phase II: - small # patients with disease - "Dose it work?" - treatment efficacy, optimal dosing and adverse effects Phase III: - large # patients randomly assigned to either treatment or placebo/control - "Is it as good or better?" - compares new treatment to standard of care Phase IV: - postmarketing surveillance of patients after treatment is approved - "Can it say?" - detects rare or long term adverse effects and can result in treatment being withdrawn from the market
Major Depressive Disorder Diagnostic criteria? Changes in sleep? RX? Persistent depressive disorder (dysthmia): Diagnostic criteria/timing
*Major Depressive Disorder* *Diagnostic criteria?* - usually lasting 6-12 months - must meet 5 of 9 criteria *SIG E CAPS*: - sleep, interest, guilt, energy loss, concentration problems, appetite, psychomotor retardation, suicidal ideation *Changes in sleep?* - decreased slow wave sleep - decreased REM latency - increased REM early in sleep cycle - repeated nighttime awakenings - early morning awakening (terminal insomnia) RX: - SSRI and CBT are first line. ECT in select patients *Persistent depressive disorder (dysthmia):* - milder depression lasting at least 2 years
In terms of the following types of child abuse, provide the Physical Abuse, Sexual Abuse: - presenting evidence - abuser - epidemiology
*Physical abuse: presenting evidence*: fractures (long bone, ribs, multiple in different stages of healing), bruises (trunk, ear, neck, pattern of implement), burns (cigarette, buttocks/thighs), subdural hematoma, retinal hemorrhages, *abuser*: - biological mother *epidemiology*: 40% of deaths in children < 1 yro *Sexual abuse* *presenting evidence:* genital, anal or oral trauma. STI. UTIS *abuser*: known to victim, usually male *epidemiology*: peak incidence is 9-12 years old If suspected, must be reported to child protective services!
Compare primary VS secondary VS tertiary VS quaternary disease prevention
*Primary*: - prevent disease BEFORE it occurs (HPV vaccination( *Secondary*: - screen early for and manage existing but asymptomatic disease (ie: PAP smear for cervical cancer) *Tertiary*: - treatment to reduce complications from disease that is on-going or has long term effects (ie: chemotherapy) *Quaternary*: - identifies patients at risk of unecessary treatment, protecting from the harms of new interventions
Risk factors for suicide completion? Most common method in US? Gender differences?
*Risk factors for suicide completion?* SAD PERSONS Sex (male), age (young or old), depression, previous attempt, ethanol/drug use, rational thinking loss (psychosis), sickness (medically ill), organized plan, no spouse or social support, stated future intent Most common method in US? - firearms - access to firearms increases risk of suicide completion Gender differences? - women try more, men succeed more
Advanced directives? Oral advance directives? Living will? Medical POA? Surrogate decision maker? Priority of surrogates? Confidentiality?
*Surrogate decision maker? Priority of surrogates? * SPOUSE > ADULT CHILDREN > PARENTS > ADULT SIBLINGS > OTHER RELATIVES
What are the following statistical tests used for? T-test? ANOVA? Chi-squared?
*T-test?* - compares differences between means of 2 groups - T is for TWO *ANOVA?* - analysis of variance, looking at the difference between means of 3 or more groups *Chi-squared?* - checks differences between 2 or more percentages or proportions of *categorical* outcomes (NOT mean values) - CHI = CATEgorical
What are some of the changes seen in the elderly/with aging with regard to: Sexual changes in men V women Sleep patterns Suicide Muscle mass/fat Intelligence What is presbycusis?
*What are some of the changes seen in the elderly/with aging with regard to:* Sexual changes in men V women: men: slower erection/ejaculation, longer refractory period women: vaginal shortening, thinning, dryness Sleep patterns: decreased REM and slow-wave sleep, increased sleep onset latency and increased early awakenings Suicide: increased rate Muscle mass/fat: lose muscle, gain fat: Intelligence: no change *What is presbycusis?* - sensorineuronal hearing loss (often of higher frequencies) due to destruction of the hair cells are the cochlear base (preserved low frequency hearing at the apex)
What are the criteria for calling something informed consent? How does consent work for minors?
*What are the criteria for calling something informed consent?* - disclosure, understanding, capacity and voluntariness *How does consent work for minors?* - minor < 18 yro - consent should be required from parents except in the following: *SEX (contraception/sti/pregnancy), DRUGS, ROCK AND ROLL*
What are the general features of cluster A personality disorders? What are the specific cluster A personality disorders?
*What are the general features of cluster A personality disorders?* - they are WEIRD odd or eccentric, inability to develop meaningful relationships. NO psychosis *What are the specific cluster A personality disorders?* 1. *Paranoid*: pervasive distrust and suspiciousness, projection is major defense 2. *Schizoid:* voluntary social withdrawal, limited social emotional expression, HAPPY to be isolated. Remember, schizoi*d* = *d*istant 3. *Schizotypal*: eccentric appearance, odd beliefs, maginal thinking. Remember Schizo*t*ypal = magical *t*hinking
What are the general features of cluster B personality disorders? What are the specific cluster B personality disorders?
*What are the general features of cluster B personality disorders?* - dramatic, emotional, or erratic - genetic associated with mood disorders and substance abuse - WILD (Bad to the Bone) What are the specific cluster B personality disorders?* 1. Antisocial (aka SOCIOPATH) - disregard for right of others, criminality, impulsivity - males > females - *must be > 18 and history of conduct disorder before 15* 2. Borderline - unstable mood and interpersonal relationships - SPLITTING -* rx: DBT* 3. Histrionic - excessive emotionality and excitability, attention seeking, sexually provocative, overly concerned with appearance 4. Narcissistic - grandiosity, sense of entitlement, lacks empathy and requires excessive admiration - often demands the best and reacts to criticism with rage
What does the Pearson correlation coefficient tell you?
*What does the Pearson correlation coefficient tell you?* - r is the degree of correlation between two values - r ranges from -1 to 0 to 1 - when the absolute value of R is closest to 1 --> stronger correlation R is - = negative correlation R is + = positive correlation
What is a null hypothesis? What is a type I error? What is a type II error?
*What is a type I error?* - stating there is an effect or difference when none exists (null hypothesis incorrectly rejected in favor of alternative hypothesis) - alpha is the probability of making a type I error - p is judged against a preset alpha level of significance, usually 0,05 such that if p < 0.05 than there is *less than a 5% chance of making a type I error* - *also known as a FALSE POSITIVE RATE* - alpha = you ABserved a difference that was not there *What is a type II error?* - stating there is not an effect or difference when one exists after all - beta = the probability of making a type II error - beta is related to statistical power (1-beta) which is the probability of rejecting the null hypothesis when it is false *you can increase POWER and decrease BETA by:* - increasing sampling size - increase expected effect size - increase precision of measurement remember: there is POWER in NUMBERS
What is child neglect? What is the evidence? What do you do?
*What is child neglect? What is the evidence? What do you do?* - failure to provide child with adequate food, shelter, supervision, education, affection - most common form of maltreatment - evidence = poor hygiene, malnutrition, withdrawal, impaired social/emotional development, failure to thrive Must be reported to child protective services
What is the confidence interval? How is it calculated? What is the Z value for 95% and 99% CI?
*What is the confidence interval?* - the range of values within which the true mean of the population is expected to fall, with a specified probability - the confidence interval of 95% is often used, corresponding to p < 0.05 *How is it calculated?* -Confidence Interval = mean +/- Z(SEM) *What is the Z value for 95% and 99% CI?* for 95% confidence interval, Z = 1.96 for 99% confidence interval, Z = 2.58 If the 95% CI for a mean difference between two variable includes 0, then there is no significant difference and Ho is not rejected If the 95% CI for odds ratio or RR includes 1, H0 is not rejected If CIs between 2 groups do not overlap --> statistically significant difference exists If the CI's between 2 groups overlap --> usually no significant difference exists
What is the number needed to treat? What is the number needed to harm?
*What is the number needed to treat?* - number of patients needed to be treated for 1 patient to benefit - NNT = 1/ARR *What is the number needed to harm?* - number of patients needed to be exposed to a risk factor for a patient to be harmed - NNH = 1/AR
What is the power of a study? How can it be calculated?
*What is the power of a study?* - power is the ability of a study to detect a difference between groups when such a difference truly exists - power relates to Type II error (beta) which is the probability of concluding there is no difference between groups when one truly exists *How can it be calculated?* Power = 1 - Beta
When do post-partum mood disturbances occur? Define the following variations: Maternal (postpartum) "blues" Postpartum depression Postpartum Psychosis
*When do post-partum mood disturbances occur?* - onset within 4 weeks of delivery Define the following variations: *Maternal (postpartum) "blues":* - 50-85% incidence rate - depressed affect, tearfulness, fatigue 2-3 days after delivery - usually resolves in 10 d - RX is supportive *Postpartum depression:* - 10-15% incidence rate - depressed affect, anxiety, poor concentration - RX: CBT and SSRIs *Postpartum Psychosis*: - 0.1-0.2% - psychosis, increased risk with hx of bipolar or psychotic disorder - RX: hospitalization and atypical antipsychotics. If not helping, ECT OK.
Recall bias definition: examples: strategy to reduce bias:
*definition:* - awareness distorts recall in subjects - common in retrospective studies *examples:* - patient with disease recalls exposure after learning about similar cases *strategy to reduce bias:* - decrease time from exposure to follow up
Lead-time bias definition: examples: strategy to reduce bias:
*definition:* - early detection is confused with increased survival *examples:* - early detection makes it seems like survival has increase but the natural history of the disease has not changed *strategy to reduce bias:* - measure "back-end" survival (adjust survival to severity to disease at time of diagnosis)
Selection Bias definition: examples: strategy to reduce bias:
*definition:* - error in assigning subjects to a study group resulting in an unrepresentable sample - most commonly a sampling bias *examples:* - Berkson bias --> selecting population from hospital is less healthy than general population - Healthy worker effect --> studying a population that is healthier than the general population - Non-response bias --> participating subjects differ from non-responders in meaningful ways *strategy to reduce bias:* - randomization - ensure the choice of right comparison/reference group
Measurement bias definition: examples: strategy to reduce bias:
*definition:* - information gathered in a systematically distorted way *examples:* - association between HPV and cervical cancer not observed when using non-standardized classifications *strategy to reduce bias:* - use objective, standardized, and previously tested methods of data collection that are planned ahead of time
Observer-expectancy bias definition: examples: strategy to reduce bias:
*definition:* - researcher's belief in the efficacy of a treatment changes the outcome of that treatment (e: Pygmalion Effect; self-fulfilling prophecy) *examples:* - observer expecting to see signs of improvement is more likely to document positive outcomes *strategy to reduce bias:* - blinding - use of placebo
Procedure bias definition: examples: strategy to reduce bias:
*definition:* - subjects in different groups are not treated the same *examples:* - patients in treatment group spend more time in highly specialized hospital units *strategy to reduce bias:* - blinding - use of placebo
Confounding bias definition: examples: strategy to reduce bias:
*definition:* - when a factor is related to both the exposure and the outcome, but not on the causal pathway thus distorts the effect of an exposure on outcome *examples:* *strategy to reduce bias:* - multiple, repeated studies - matching - restriction - randomization
design: measurement/example:
*design:* *measurement/example: *
Cross-sectional study design: primary ?: measurement/example:
*design:* - collects data from group of people to assess frequency of disease (and related risk factors) are a particular point in time - asks *"What is happening?"* *measurement/example: * - disease prevalence - can show risk factor associated with disease - does not establish causality
Case-control study design: primary ?: measurement/example:
*design:* - compares a group of people with a disease to a group without disease - looks at prior exposure or risk factor - asks "What happened?" *measurement/example: * - Odds ratio - "patient with COPD had a higher odds of history of smoking that those without COPD"
Cohort Study design: measurement/example:
*design:* - compares a group with a given exposure or risk factor to a group without exposure - looks to see if exposure affects likelihood of disease - can be prospective ("Who will develop disease?") or retrospective ("Who developed the disease, ie: exposed vs non-exposed?") *measurement/example: * - relative risk (RR) - "smokers have a higher risk of developing COPD than nonsmokers"
Adoption Study design: measurement/example:
*design:* - compares siblings raised by biological vs non-biological parents *measurement/example: * - heritability and influence of environmental factors
Twin concordance study design: measurement/example:
*design:* - compares the frequency with which both monozygotic twins or both dizygotic twins develop the same disease *measurement/example: * - measures heritability and influence of environmental factors (nature vs nuture)
Narcolepsy what? symptoms? rx?
*what?* -disordered regulation of sleep-wake cycles - caused by decreased hypocretin (orexin) production in the lateral hypothalamus *symptoms?* - excessive daytime sleepiness - hypnagogic (GOING to sleep) or hypnopompic (POMPOUS upon awakening) hallucinations - nocturnal and narcoleptic sleep episodes that start with REM sleep - cataplexy (loss of muscle tone with strong emotional stimulus) *rx?* - stimulants (amphetamine, modafanil) - nighttime sodium oxybate (GHB)
What is depression with atypical features?
- differs from classical depression - characterized by mood reactivity (being able to experience improved mood in response to positive events) - reversed vegetative symptoms (hypersomnia, hyperphagia) - leaden paralysis (heavy feeling in arms and legs) - long standing interpersona rejection sensitivity - most common subtype of depression RX: SSRIs and CBT MAO are effective but not first line
*Delusional Disorder*
- fixed, persistent false belief lasting *> 1 month* - functioning need not be impaired otherwise - can be shared by individuals in a close relationship (folie a deux)
Sleep Terror Disorder
- periods of terror with screaming in the middle of the night. Occurs during slow-wabe/deep sleep - most common in children - occurs during non-REM sleep (no memory of arousal)
Odds Ratio
- used in case-control studies - odds the group with the disease (cases) were exposed to a risk factor (a/c) divided by the odds that the group without the disease was exposed (b/d)
Generalized anxiety disorder vs adjustment disorder
GAD : lasting > 6 months Adjustment disorder: lasting < 6 months
Explain the difference between incidence, prevalence and recurrence
Incidence = # new cases/# people at risk Prevalence = #existing cases/total # people Note that: - prevalence approximates incidence for SHORT duration disease (like the common cold) - prevalence >> incidence for chronic diseases due to large # of existing cases (ie: diabetes)
Operant conditioning? What is reinforcement vs punishment vs extinction?
Learning in which particular action is followed by a desired reward or removal of aversive stimulus. Usually deals with voluntary responses. *Reinforcement*: target behavior is followed by a desirable reward *Punishment*: repeated application of aversive stimulus or removal of desired reward to extinguish unwanted behavior *Extinction*: discontinuation of reinforcement eventually eliminates behavior.
Hypomanic episode: definition? duration?
Like a manic episode except the mood disturbance is not severe enough to cause marked impairment in social/occupational functioning or to necessitate hospitalization. No psychotic features . Lasts at *least 4 consecutive days*
Compare and contrast MEDICARE vs MEDICAID
Medicare and medicaid are federally funded programs that originate from amendments to the social security act. Medicar*E* is for the *E*lderly - for patients >= 65 - < 65 with certain disabilities - those with ESRD *the 4 parts of medicare* - part A = hospital insurance - part B = basic medical bills - part C = A+B approved by private companies - part D = prescription drugs Medicai*D* is the for the *D*esitute - low income families
Classical conditioning
Natural response is elicited by a condition or learned stimulus, that previously was presented in conjunction with an unconditioned stimulus
Grief
Normal grief is characterized by shock, denial, guilt, sadness, anxiety, yearning and somatic symptoms. Hallucinations of deceased person are common. DUration varies widely, usually < 6 months.
Draw a 2/2 table for the determination of the sensitivity/specificity of a drug. How do you calculate sensitivity? What does it mean? How you you calculate specificity? What does it mean? What is the PPV? What is the NPV?
Note that: - sensitivity and specificity are FIXED properties of the test - PPV and NPV vary depending on the disease prevalence *Sensitivity*: - portion of all people with disease who test positive - alternatively --> the probability that when the disease is present, the test is positive - values approaching 100% are desirable for ruling out disease and indicates a *low false-negative rate* = TP/(TP+ FN) = 1 - false negative rate remember: *SN-N-OUT*: high SENsitive test when Negative routs disease OUT --> thus GOOD for SCREENING *Specificity*: -proportional of all people with disease who test negative, or the probability that when the disease is absent the test is negative - value approaching 100% is desirable for ruling a disease in and indicates a low false positive rate = TN/(TN+FP) = 1 - false positive rate remember: *SP-P-IN*: highly SPecific test, when POSITIVE, rules disease in --> thus GOOD for CONFIRMATION *PPV* - proportion of positive test results that are TP - corresponds to the probability that a person with a positive test result actually has the disease - PPV varies directly with pretest probability (baseline risk, such as prevalence of disease) - high pretest probability --> high PPV note: - explained alternatively, if a disease is more prevalent than that means it is MORE likely that a patient with positive test result actually has the disease *NPV* - proportion of negative test results that are true negative -probability that person with a negative test result actually does not have the disease - NPV varies inversely with prevalence or pretest probability --> high pretest probability --> low NPV (this is became the probability of a TRUE negative is higher in a population with low disease prevalence)
Precision vs Accuracy
Precision: - the consistency and reproducibility of a test (reliability) - random error will decrease the precision of a test - an INCREASE in precision = decrease in standard deviation - an INCREASE in precision = increase in statistical power (1-beta) Accuracy: - the trueness of a test measurement (validity) - the absence of systematic error or bias in a test (systematic error will DECREASE the accuracy in a test)
MATURE defenses
Remember --> *mature adult wears a SASH* - sublimation - altruism - suppression - humor
What are the effects of infant deprivation?
Remember the 4 W's: - *weak* (failure to thrive) - *wordless* (poor language/socialization) - *wanting* (reactive attachment disorder --> infant is withdrawn/unresponsive to comfort) - *wary* (lacks basic trust) Deprivation for > 6 months can lead to irreversible changes. Severe deprivation can result in infant death.
What are the three clusters of personality disorders?
Remember, WEIRD = A WILD = B WORRIED = C
Schizophrenia - diagnostic requirement Brief Psychotic Disorder Schizophreniform Disorder Schizoaffective Disorder
Schizophrenia - *lasting > 6 months* requires 2 of following, with at least 1 of 1-3: 1. delusions 2. hallucinations 3. disorganized speech 4. disorganized or catatonic behavior 5. negative symptoms note: - cannabis use associated with psychosis/schizophrenia - shows *ventriculomegaly* on MRI - lifetime prevalance of 1.5%, male onset earlier than female - treat with APs *Brief Psychotic Disorder:* - *lasting < 1 month* - usually stress related *Schizophreniform Disorder:* - the FORMATIVE aspects of schizophrenia - lasting < 6 months *Schizoaffective Disorder:* - >2 weeks of hallucinations/delusions WITHOUT major mood episode PLUS periods of concurrent major mood episode with SZ symptoms
Absolute Risk Reduction
The difference in risk (not the proportion) attributable to the intervention as compared to a control Example: If 8% of people who receive a placebo vaccine develop the flu vs 2% of people who receive a flui vaccine then ARR = 8% - 2% = 6% = 0.06
Attributable risk
The difference in risk between exposed and unexposed groups or the proportion of disease occurrences that are attributable to the exposure Example: - if risk for lung cancer is 21% in smokers and 1% in nonsmokers than the attributable risk of lung cancer of smoking is 20%
Relative Risk Reduction
The proportion of risk reduction attributable to the intervention as compared to a control. Example: - if 2% of patients who receive a flu shot develop the flu, while 8% of unvaccinated patients develop the flu, then RR = 2/8 = 0.25 and RRR = 0.75 RRR = 1 - RR
Transference Countertransference
Transference: patient projects feelings about formative or other important person onto physician Countertransference: doctor projects feelings about formative or other important persons onto patient
Relative Risk
Used in cohort studies. - risk of developing a disease in the exposed group divided by risk in the unexposed group. If RR = 1.0 (*null value*), then there is no association between exposure and disease ( If RR < 1.0, then exposure is associated with decreased risk of disease If RR > 1.0, exposure is associated with increased risk of disease Example: - if 21% smokers get cancer VS 1% of nonsmokers than RR = 21/1 = 21 Note that: - RR by itself does not account for the possibility that chance alone is responsible for the results - the 95% CI and p-value are measures of statistical significance that can help strengthen the findings of the study using RR - for a result to be considered statistically significant its *corresponding CI must NOT contain the null value* - when the 95% confidence interval does NOT include the null value this gives a corresponding *p-value of <0.05*
What are the general features of cluster C personality disorders? What are the specific cluster C personality disorders?
What are the general features of cluster C personality disorders? - WORRIED (Cowardly, Compulsive, Clingy) - anxious or fearful, genetic association with anxiety disorders *What are the specific cluster C personality disorders?* 1. Avoidant: - hypersensitive to rejection - socially inhibited, timid - desires relationships with others 2. Obsessive-Compulsive: - order, perfection, control - EGO-SYNTONIC! 3. Dependent: - submissive and clingy - excessive need to be taken care of - low self-confidence
What is vulnerable child syndrome?
When patients perceive their child as being especially susceptible to illness or injury. Usually follows a serious illness or life-threatening event. Can result in missed school or overuse of medical services.
Malingering vs factitious disease
malingering: Faking for secondary gain (money, compensation, etc) factitious: faking for primary gain (Munchausen and Munchausen by Proxy)
ECT used for? SE? pregnancy?
used for?: - treatment refractory depression, depression with psychotic symptoms, and acutely suicidal patients - produces grand-mal seizure in an anesthetized patient SE?: - disorientation - temporary headache - partial antero/retrograde amnesia usually resolving in 6 months pregnancy?: - safe in pregnancy
Delirium vs Dementia
Delirium = reversible Dementia = not
*Manic Episode* definition? diagnosis?
Distinct period of abnormally and persistently elecated, expansive or irritable mood and abnormally and persistently increased activity or energy *lasting more than 1 week* *diagnosis requires hospitalization or at least 3 of the following*: remember *DIG FAST* - distractability - irresponsible - grandiosity - increased activity/agitated - decreased need for SLEEP - talk (pressured speech)
